SAMUELxLILIENTHAL.xM.D.. 

22C  West  34th  S    -^feET. 


■  '^iJi^JSt'^  '' 


THE  PROKbRI N    ^P_  ^ 

HataniffliiliiiHlCilItinftkiiPaalc. 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GIFT  OF 

Dr.    E.    BELT 


August 


ON 


EENAL   AND    UEII^AEY 


AFFECTIOI^S 


BY 


W.  HOWSIIIP  DICKINSON^,  M.D.CANTAB.,  F.E.C.P. 

PHYSICIAJI  TO,   AND   LECTURER  ON'  MEDICINE  AT,    ST.   GEORGE'S  HOSPITAL 

CONSULTING   PHYSICIAN  TO  THE   HOSPITAL  FOR  SICK  CHILDREN 
CORRESPONDING   MEMBER  OF   THE   ACADEMY  OF  MEDICINE   OF  NEW  YORK 


MISCELLAIN'EOUS    AFFECTIONS    OF 
THE    KIDjS'EYS    A]S[D    UEIlSrE 


NEW  YORK 

WILLIAM    WOOD    &     COMPANY 

1885 


PREFACE. 


In  presenting  this  work  to  the  public  I  have  to  apologize  for  its  tardy- 
completion.  The  delay  has  been  partly  caused  by  the  demands  of 
active  professional  work,  and  partly  by  my  desire  to  incorporate  the  re- 
sults of  the  experience  thus  acquired. 

It  was  my  design  to  follow  the  publication  of  Albuminuria^  with 
an  account  of  the  other  renal  and  urinary  diseases  sufficient  for  the 
practitioner,  and  not  too  lengthy  for  the  student.  If  I  have,  as  I  fear, 
erred  in  the  direction  of  amplification,  it  has  been  from  the  desire  to 
be  clinical ;  not  merely  to  give  conclusions,  but  the  grounds  of  them. 
I  notice  with  regret  as  a  substantia]  evil  the  bulk  to  which  the  book 
has  swollen.  Paper  of  some  thickness  was  needed  for  the  proper  dis- 
play of  the  woodcuts,  and  I  have  not  thought  it  well  to  save  space  by 
contracting  tlie  type.  I  am  assured  that  much  of  any  interest  which 
may  be  found  will  be  in  the  clinical  and  pathological  cases,  but  never- 
theless it  is  possible  that  the  value  of  some  of  them  may  not  be  thought 
commensurate  with  their  weight.  It  was  my  intention  to  have  pre- 
sented the  work  in  one  volume ;  but  I  have  thought  that  the  con- 
venience of  the  reader  would  be  best  served  by  so  far  departing  from 
the  original  plan  as  to  issue  each  part  in  a  separate  cover,  each  with  a 
separate  table  of  contents. 

I  have  not  hesitated  to  fill  up  the  deficiencies  of  my  own  observa- 
tion with  that  of  others  ;  and  where  my  opportunities  have  been  small, 
as  with  regard  to  parasites,  I  have  been  content  to  present  the  existing 
state  of  knowledge  little  else  than  as  a  compilation. 

I  have  considered  in  one  place  the  structural  alterations  of  the  kid- 
ney, together  with  the  results  tliey  produce  ;  and  in  another  the  lead- 
ing alterations  of  the  urine,  with  the  changes  to  which  they  are  due. 
Many  subjects  have  thus  been  shown  from  two  points  of  view,  and  a 
certain  amount  of  repetition  entailed ;  but  not  otherwise  could  the 
mutual  relations  as  well  as  the  individual  characteristics  of  tlie  several 
disorders  be  presented. 

With  the  existing  abundance  of  works  devoted  to  the  purpose,  I 
have  not  thought  it  necessary  to  give  space  to  methods  of  urinary  ex- 
amination ;  nor  have  I  attempted  to  deal  at  large  with  changes  which 

'  See  Am.  Publisher's  Note  at  end  of  Preface. 


IV 


PREFACE. 


tlic  urine  presents  in  connection  with  diseases  external  to  tlie  kidneys, 
and  not  manifested  especially  by  their  means ;  but  I  have  regarded 
with  a  somewhat  wide  ocoi)e  its  more  promineni  morbid  states,  and  tlie 
conditions  wliich  attend  its  absence  and  its  superabundance.  I  have 
dealt  fully  witli  the  circumstances  of  phospliatic  excess,  and  of  the 
additions  'of  sugar,  albumin,  chyle,  and  blood.  I  have  not  given  a 
separate  chai)ter  to  ])uruk'nt  urine ;  since,  so  far  as  tliis  can  be  con- 
sidered apart  from  surgery,  1  judged  that  it  had  found  suthcient  men- 
tion under  tlie  headings  of  Pyelitis  and  Abscess.  I  have  entered  Avith 
some  detail  into  the  conditions  of  urine  and  of  system  which  occur  with 
the  formation  of  calcuH. 

In  preparing  for  the  press  the  portion  of  the  work  which  is  now 
presented  to  the  public,  pains  have  been  taken  to  make  each  subject 
level  with  tlie  time ;  but  even  in  the  interval  between  printing  and 
pubHcation  some  cases  have  progressed  in  a  manner  I  sliould  liave  been 
glad  to  have  recorded,  and  some  researches  have  been  made  and  opin- 
ions expressed  which  were  excluded,  not  by  choice,  but  by  date.  Cases 
in  renal  surgery  have  presented  tliemselves  which  it  was  not  possible  to 
introduce,  but  tlie  principles  enunciated  would  not  have  been  thereby 
altered.  Tlie  chapter  on  disseminated  suppuration  has  received  some 
additional  experience  in  the  shape  of  a  postscript,  together  with  refer- 
ence to  some  recent  views  on  ''catheter  fever."  The  chapter  in  Part 
I.  referring  to  the  pathology  of  diabetes,  which  was  published  in  the 
year  is 77,  has  been  re- written,  which  was  rendered  necessary  by  the 
discussions  which  it  has  provoked,  and  the  further  researches  which  it 
has  instigated. 

The  publication  of  this  work  in  portions  has  necessitated  a  mode  of 
arrangement  in  which  logical  sequence  has  sometimes  given  way  to 
convenience  :  but  it  is  hoped  that  the  disjointed  parts  will  fall  together 
without  violence,  and,  with  the  help  of  the  index,  present  a  fairly 
accessible  as  well  as  a  sutticiently  inclusive  account  of  the  diseases  of 
the  kidneys,  and  the  disorders  mainly  declared  by  their  secretion. 

9  Chesterfield  Street,  May  Fair: 
January,  1885. 

j}^ote  hy  the  American  Publishers. 

The  treatise  on  Albuminuria  by  the  author  of  this  work  was  pub- 
lished in  Wood's  Lil)rary  of  Standard  Medical  Authors  for  1881. 

The  numerous  cases  cited  in  detail  in  the  English  edition  of  this 
volume  have  been  omitted  in  this  edition  in  order  somewhat  to  reduce 
its  size.  It  will  be  perceived  that  the  text  of  the  work  has  been  so 
prepared  that  this  omission  in  no  degree  interferes  with  its  continuity, 
nor  does  it  limit  its  authority. 

WM.  WOOD  &  CO. 


OOITTEE"TS. 


MISCELLANEOUS  AFFECTIONS   OF  THE   KIDNEYS  AND  URINE. 


CHAPTER  I. 

ABSCESS,   OR  CIRCCTMSCRIBED  INFLAMMATION  OF  THE  KIDNEY. 

p 

Causes  of  renal  abscess — Abscess  from  external  violence;  from  irritant  drugs; 
with  pyaemia — The  surgical  kidney — Uriseptic  abscess — Urinary  or  cathe- 
ter fever,   .......... 

CHAPTER    II. 


Pathological  changes — Causes — Urinary  alterations — Characters  of  healthy 
epithelium  from  different  parts  of  urinary  tract — Sj'^mptoms,  course,  re- 
sults, and  treatment  of  pyelitis,  .  .  .  .  ,  .16 

CHAPTER  III. 

SUPPURATIVE  PERINEPHRITIS. 

Position  and  exits  of  matter  outside  kidney;  its  sources  and  causes — Ply- 
mouth Dockyard  disease — Puerperal  abscess.  From  perforation  of  gall- 
bladder, pyajmia,  fevers,  etc. — Symptoms,  duration,  urinary  charac- 
ters, and  treatment  of  perinephritis,     .  .  .  .  .  .23 

CHAPTER  IV. 

THROMBOSIS  AND  EMBOLISM. 

Thrombosis — Morbid  anatomy;  causes,  organic  antecedents,  and  symptoms — 
Mortality  when  complete  and  when  partial — Embolism — Morbid  anatomy 
— Symptoms — Urine — Aneurism  of  renal  artery  consequent  upon  embolic 
obstruction,  .  .  .  .  .  .  .  .  .30 

CHAPTER  V. 

GENERAL  RELATIONS  OF  RENAL  TUMORS. 

Their  anatomical  relations — Position  with  regard  to  bowels  subject  to  some 
variation — Abdominal  presentation ;  its  varieties — Urine — Renal  tumors 
how  distinguished  from  those  of  liver,  spleen,  ovary,  peritoneum,  supra- 
renal bodies,  and  absorbent  glands — Cases  illustrating  the  similarity  of 
the  last  with  renal  tumors,        .  .  .  .  .  .  .37 

CHAPTER  VI. 

PATHOLOGY  AND  VARIETIES   OF  RENAL  TUMORS. 

Their  kinds  enumerated — Malignant  growths  generally  considered — Distribu- 
tion of  growths  secondary  to  those  in  kidney — Extension  of  growths 
from  kidney — Minute  anatomy  and  relations  of  carcinoma,   sarcoma. 


VI  CONTENTS. 


PAGE 


fibrous  and  fibro-fatty  tumors,  melanosis,  villus,  lymphadenoma,  leuk- 
haemic  tumors,  angioma,  syphiloma,  fatty,  bony,  calcareous,  and  carti- 
laginous growths,  .  .  .  .  •  .  .  .47 

CHAPTER  VII. 

CUNICAL    HISTORY,    SYMPTOMS.    AND    TREATMENT     OF    MALIGNANT    DIS- 
EASE OF  THE   KIDNEY. 

Its  exciting  causes— Symptoms— Tumefaction,  pain,  paraplegia,  cachexia, 
hfematuria — Urine— Results  of  dissemination  and  encroachment — Dura- 
tion in  children  and  adults— Treatment  by  excision  and  palliation,  .     70 

CHAPTER    VIII. 

TUBERCLE     OF     KIDNEY. 

Patholog}'.  broadly  and  with  microscopic  detail— How  associated  with  tuber- 
cle elsewhere— Frequency  in  children  and  adults,  and  at  different  ages — 
Exciting  causes — Symptoms,  local  and  general — Abdominal  tumor — Con- 
sequent lardaceous  disease,  extra-renal  and  psoas  abscess — Urine — Dura- 
tion and  prospects — Medical  and  surgical  treatment  .  .  .79 

CHAPTER  IX. 

HYDRONEPHROSIS  AND  PY'ONEPHROSIS. 

Greneral  description — Subjects  and  causes  of  hydro-  and  pyo-nephrosis — 
Pathological  changes  with  hydronephrosis — Dilatations  and  cysts  simu- 
lating it — Double  hydronephrosis — Single  hydronephrosis,  diagnostic 
errors,  causes  of  death — Pyonephrosis — Treatment,  medical  and  surgical, 
of  both  conditions  .  .  .  .  .  .  .  .94 

CHAPTER  X. 

CYSTIC  DISEASE  OF  KIDNEY. 

Varieties — The  large  cystic  kidney  minutely  descrilied — Its  origin  and  nature 
— Subjects — Its  frequent  latency  and  distinctive  symptoms — Urine — Tu- 
mefaction—  Congenital  cvstic  disease — Solitary  cysts  —  Paranephric 
cysts,  .  .  '.  .  .  .  .  .  .        .  109 

CHAPTER  XI. 

RENAL  CALCTLI  IN  GENERAL  AND  PARTICULAR,  WITH  THEIR  CAUSES. 

Classification  of  calculi;  their  relative  frequency  as  indicated  by  the  museums 
of  London — General  structure  of  calculi — Ord's  views — Their  geographi- 
cal distribution  and  relation  to  water,  food,  climate,  and  race — Uric  acid 
stones;  and  diathesis — Urates — Xanthine — Oxalate  of  limestones,  and  the 
oxalic  diathesis — Phosphatic  calculi  and  the  phosphatic  diathesis — Calcic 
carbonate — Cystine  and  the  cystine  diathesis — Indigo  stones — Fibrinous 
and  blood  calculi — Urostealith — Differential  diagnosis  of  renal  calculi,     .  120 

CHAPTER    XII. 

PATHOLOGICAL  CONSEQUENCES,    CLINICAL    RELATIONS,    AND    SYMPTOMS  OF 
RENAL  CALCULI   IN  GENERAL. 

Position  and  local  effects  of  renal  stones — Their  clinical  relations  and  sj'mp- 
toms — Ages  at  death  icith  and  o/ renal  calculi — Their  various  symptoms, 
pain,  tenderness,  grating  appreciable  to  touch — Posture — Affections  of 
testicle  and  bla<ider— Hieinaturia  in  relation  to  movement— Its  charac- 
ters and  differential  diagnosis— Passage  of  stone — Case  illustrating  its 
symptoms — Modes  of  death,       .  .....  155 

CHAPTER    XIII. 

ON  CERTAIN  RESULTS  OF  RENAL  CALCULI. 

Pyelitis — Pyonephrosis — Various  courses  taken  by  pus  of  calcareous  origin — 
Discharging  superficially  into  peritoneum,  bowels,  stomach,  and  bron- 


CONTENTS.  Vll 

PAOE 

chial  tubes— Suppression  of  urine  from  calculi — Various  conditions  in 
which  this  occurs — Its  symptoms  and  results — Insanity  and  epilepsy  with 
renal  stones,  .........  168 

CHAPTER  XIV. 

ON  THK  TREATMENT   OF  STONE  IN  THE  KIDNEY. 

Regulation  of  movement  and  of  diet — Treatment  of  pain,  hemorrhage,  pyeli- 
tis, renal  colic,  and  suppression — Renal  lithotomy  and  excision  of  kidney 
— Tabulation  of  cases — History  and  discussion  of  the  solvent  treatment 
of  calculi  by  various  nostrums,  reagents  and  waters,  .  .  .  177 

CHAPTER  XV. 

MISPLACEMENT,    DISPLACEMENT,    AND   MOBILITY   OF  THE    KIDNEY. 

Congenital  misplacement — Movable  or  displaced  kidney  as  an  acquired  condi- 
tion— Sex  and  age  of  subjects — Etiology — Signs — Abdominal  relation  of 
tumors  shown  in  diagrams — Symptoms  and  results — Diagnosis  and  ter- 
minations— Medical  treatment  by  pressure,  etc. — Surgical  by  excision  and 
fixation,     .....  ....  204 

CHAPTER  XVI. 

URINARY   PARAPLEGIA. 

Theory  of  reflex  paralysis — Criticism  of  Stanley's  cases  and  of  those  of 
Graves  and  d'Etiolles — Views  of  Gull — Conclusion  adverse  to  the  reflex 
theory,       .  .  .  .  .  .  .  .  .  .315 

CHAPTER  XVII. 

DISEASES  OP  THE   URETERS   AND  LARGE  BLOOD-VESSELS, 

Congenital  imperfections  of  ureters;  iiijuries  by  violence — Inflammation — 
Tubercle  and  cancer — Stricture  and  dilatation  of  ureters — Their  involve- 
ment in  diseases  external  to  tliemselves;  their  perforation  by  abscesses — 
Renal  artery — Congenital  defects;  obstruction  by  coagulum,  by  atlieroma, 
by  external  pressure — Renal  aneurism,  .....  221 

CHAPTER  XVIII. 

RENAL     PARASITES. 

Hydatids — General  description — Their  renal  localization,  signs,  and  symp- 
toms— their  association  witli  calculi,  with  paraplegia — Their  course,  du- 
ration, and  treatment — Bilharzia — Endemic  hajmaturia — History  and 
geographical  distribution  of  the  Bilharzia  —  Symptoms  —  Preventive 
and  otiier  treatment — The  strongulus  gigas — Description,  geographical 
distribution,  site,  and  symptoms — Pentastoma  denticulatum — Teti'astoma 
renale — Worms  accidentally  present  in  urinary  passages — Spurious  para- 
sites passed  with  urine  or  found  in  bladder,  ....  227 

CHAPTER    XIX. 

CHYLURIA. 

Early  and  recent  views — Geographical  distribution — Subjects  and  general 
symptoms — Urine — Duration  of  disease — Intermission  and  variations- 
Superficial  discharges  of  chyle  with  chyluria — The  filaria — Description, 
varieties,  and  natural  history — Its  effects  upon  the  human  body — Ele- 
phantiasis, etc. — Morbid  anatomy  and  pathology  of  chyluria— Treat- 
ment, ..........  251 

CHAPTER  XX. 

INTERMITTENT   HEMATURIA  OR  HEMOGLOBINURIA. 

Designations — Early  and  more  recent  descriptions — Subjects  and  antecedents 
— Malaria,  etc. — Excitants  of  attack;  cold  and  periodicity — Characters  of 
seizure — Abortive  attacks — Temperature  of  body — Intercurrent  and  con- 


Viii  CONTENTS. 

PAQB 

sequent  disorders— Urine— Blood  and  serum  under  attacks— Morbid  ana- 
tomy—General  view  of  phenomena  of  disease— Haemoglobinuria  of  other 
kinas— Analogy  with  Reynaud's  disease;  conclusions  and  treatment,       .  274 

CHAPTER  XXI. 

ON  EXCESS  OF  THE  EARTHY  SALTS.    MORE    PARTICULARLY    PHOSPHATE   OP 
LIME,   IN   THE   URINE. 

Causes  of  the  precipitation  of  phosphates— The  phosphatic  diathesis— Clinical 
significance  of  excess  of  earthy  salts  illustrated  by  cases— Quantitative 
observations  uix)n  urine — Conclusions,  .....  294 

CHAPTER    XXII. 

ALBUMINURIA  GENERALLY  CONSIDERED    IN    RELATION   TO    RENAL  AND  OTHER   DIS- 
ORDERS. 

Tests  for  albumin  compared— Reactions  of  peculiar  forms  of  albumin,  pep- 
tone, and  {,'lobul in— General  significance  of  albuminuria;  its  frequency 
and  its  causes— Albuminuria  as  a  result  of  renal  diseases  and  disturb- 
ances; with  pneumonia,  cholera,  and  pyrexia— Albuminurrti  of  nervous 
origin;  with  exophthalmic  goitre;  of  adolescents — Albuminuria  from  al- 
terations in  blood,  hydraemia,  scurvy,  and  purpura,  .  .  .  300 

CHAPTER    XXIII. 

HEMATURIA. 

Means  of  detection  of  blood  in  urine;  its  sources — Renal  haematuria;  from 
various  organic  changes  and  congestive  and  febrile  states;  from  stone 
and  growths — Vesical  haematuria;  from  cancer,  villus,  and  nsevus — 
Vicarious  hfematuria.  Haematuria  from  mental  emotion;  with  scurvy 
and  purpura,  especially  in  connection  with  the  improper  feeding  of  in- 
fants— Simple  heematuria — Malarial  haematuria — The  treatment  of  hsema- 
turia,  ..........  317 

CHAPTER  XXIV. 

SUPPRESION    OF    URINE. 

Suppression  from  renal  disease;  with  various  forms  of  albuminuria;  with 
disseminated  and  other  forms  of  abscess;  after  surgical  operations;  ob- 
structive from  stone,  hydronephrosis,  and  growths — General  description 
of  obstructive  suppression— Suppression  from  arterial  stoppage — Sup- 
pression from  systemic  causes,  concussion,  collapse,  poisqps,  cholera, 
ague,  and  intestinal  obstruction,  ......  328 

INDEX, 339 


LIST  OF  ILLUSTEATION^S. 


FIG.  PAGE 

1.  Dilated  kidney  tubes  from  case  of  surgical  or  uriseptic  abscess,         .        .  9 

2.  Plugs  in  renal  vessels  surrounded  by  pus-corpuscles,  from  case  of  urisep- 

tic abscess, 10 

3.  Kidney  converted  into  obsolete  bag  of  earthy  matter  as  result  of  pye- 

litis,      17 

4.  Varieties  of  epithelium  from  urinary  tract  in  health,  .         .         .        .20 

5.  Embolic  block  in  kidney,  with  obstruction  of  renal  artery,         .         .         .34 

6.  Abdominal  aspects  of  renal  tumors 41 

7.  Two  diagrams  illustrating  case  in  which  a  renal  tumor  was  simulated 

by  encephaloid  of  the  lumbar  glands, 44 

8.  Diagram  illustrating  case  in  which  a  renal  tumor  was  simulated  by 

a  cystic  tumor  of  the  lumbar  glands,  relations  as  observed   during 

life,             44 

9.  Eelatious  of  tumor  referred  to  in  previous  woodcut,  after  death,        .        .  45 

10.  Diagram  illustrating  casein  which  a  renal  tumor  was  simulated  by  one 

of  mesenteric  glands,  during  life,            .......  45 

11.  Relations  of  tumor  referred  to  in  previous  woodcut,  after  death,       .        .  45 

12.  Secondary  encephaloid  of  kidney,  in  microscopic  section,  .         .         .54 

13.  Round-celled  sarcoma  of  kidney  of  very  malignant  kind  from  a  child    13 

months  old,  in  microscopic  section, 56 

14.  Lai'ge  round-celled    sarcoma   from  man  aged  34,  in  microscopic   sec- 

tion,              57 

15.  Small  round-celled   sarcoma  simulating    encephaloid,  microscopic  sec- 

tion  i  57 

16.  Malignant  round-celled  sarcoma,  which  in  the  recent  state  resembled  a 

mass  of  coagulum,  microscopic  section, 58 

17.  Malignant  spindle-cell  sarcoma  simulating  scirrhus,  from  a  man  58  years 

of  age,  microscopic  section 58 

18t  Section  from  another  part  of  the  tumor  referred  to  in  preceding  wood- 
cut,    ...                 59 

19.  Melanosis  of  kidney,  naked  eye  appearance, 61 

20.  Microscopic  appearance  of  one  of  the  melanotic  deposits,  .        .         .         .63 

21.  Villus  of  kidney,  naked  eye  appearance, 63 

22.  Microscopic  appearance  of  cortical  tissue  of  a  kidney  affected  with  villus,  64 

23.  Microscopic  appearance  of  a  villus  filament  from  kidney  represented  in 

the  preceding  woodcut, 65 

24.  Tuberculous  kidney  as  seen  with  the  naked  eye, 80 

25.  Tuberculous  excavation  of  kidneys  together  with  membranous  pyelitis, 

naked  eye, 81 

26.  Caseous  and  nuclear  growth  in  acute  tubercle  of  kidney,  as  seen  micro- 

scopically, from  a  child,  .         .         • 82 

27.  Tubercle  arouad  an  artery  in  cortical  tissue  of  kidney,  from  same  subject 

as  preceding  cut 83 

28.  Large  cells  from  a  kidney  which  had  the  naked-eye  appearance  of  tuber- 

cular disease,  from  a  woman  who  had  tubercle  elsewhere,           .         ,  83 

29.  Similar  cells  from  another  part  of  the  same  organ, 84 

30.  Microscopic  section  of  pelvic  membrane  of  a  tuberculous  kidney,      .         .  84 

31.  Tuberculous  kidney  as  felt  during  life  in  case  of  Ann  Evans,     .         .        .90 

32.  As  displayed  after  death  in  same  case, 90 

33.  Tuberculous  kidney  as  felt  during  life,  formerly  tapped  as  hepatic,           .  90 


LIST    OF    ILLUSTRATIONS. 


Fia. 


PAOR 


34.  Post-mortem  relations  of  kidney  referred  to  in  preceding  cut,    .        .        .90 

35.  Kidney  of  which  the  pelvis  and  calyces  are  dilated  in  consequence  of  ob- 

struction by  calculus, 99 

30.  Kidney  dilated  into  a  translucent  hydronephrotic  sac,        ....  100 

37.  Large  cystic  kidney  as  presented  to  the  naked  eye 110 

38.  Cyst  from  large  cystic  kidney  showing  epithelial  lining,  microscopic,       .  Ill 

39.  Cyst  in  large  cystic  kidney  containing  detached  tubes,  microscopic,  .  112 

40.  Uric  acid  renal  stone,  which  weighed  7*  ounces,  naked-eye  section,  .  129 

41.  Several  small  uric  acid  calculi  from  the  kidney, 129 

42.  Uric  acid  calculus  from  kidney,  of  characteristic  shape,      ....  129 

43.  Pisiform  uric  acid  calculi,  passed  from  the  kidney  during  life,    .         .         .  130 

44.  Minute  round  calculi  of  oxalate  of  lime,  of  which  a  great  number  resem- 

bling pearls  were  found  in  a  dilated  kidney,  .....  137 

45.  Large  renal  calculus  of  oxalate  of  lime  as  shown  in  section,       .         .         .  137 

46.  Group  of  remarkable  pointed  calculi  of  oxalate  of  lime,  which  were  found 

after  deatli  in  a  kidney  which  had  been  accidentally  ruptured,   .         .  138 

47.  Two  pliosphatic  calculi  from  one  kidney 142 

48.  Renal  calcuhis,  weighing  Ik  ounces,  of  ammonio-magnesian  phosphate. 

Shown  in  section, 143 

49.  Kidney,  which  is  reduced  to  a  mere  shell,  occupied  by  enormous  mass  of 

the  mixed  phosphates,      . 156 

50.  Four  figures  illustrating  the  abdominal  presentation  of  misplaced  and 

movable  kidneys,       ...........  208 

51.  Two  figures  illustrating  the  abdominal  presentation  of  movable  or  floating 

kidneys, 209 

52.  Strongulus  gigas.  from  the  pelvis  of  the  human  kidney,  from  a  prepara- 

tion in  the  College  of  Surgeons, 244 

53.  Microscopic  appearances  of  the  molecular  base  of  chylous  urine.    Two 

views  .............  255 

54.  Globular  epithelial  cells  found  in  chylous  xirine,  case  of  E.  Parsons,  .  257 

55.  Similar  cells  from  chylous  urine  in  two  other  cases,    .....  258 

56.  Filaria  sanguinis  homiuis,  of  natural  size  and  magnified;  also  eggs,  .  265 

57.  Filaria  in  human  blood, 266 

58.  Urine  of  intermittent  haematuria,  as  seen  under  microscope,  showing 

translucent  fibrin,  granular  deposits  and  casts,  from  a  bov  five  years 
old "...  281 

59.  Urinary  deposit  of  E.  Harvey  under  attack  of  intermittent  heematuria, 

showing  granular  matter,  crystalloid  specks,  casts,  and  leucocytes,    .  282 
CO.  Urinarj'  deposit  from  J.  Dare  under  attack  of  intermittent  hfematuria, 
showing  amorphous  yellowish  matter  imbedding  j^ellow  crj'stalloid 
masses,  apparently  blood-crystals, 283 

61.  Urinary  deposit  from  C.  Evans  suffering  from  intermittent  hsematuria, 

showing  numerous  casts,  the  result  of  secondary  nephritis,  .         .  283 

62.  Section  of  kidney  in  case  of  intermittent  haematuria,  showing  haemor- 

rhage around  a  Malpighian  body  and  in  surrounding  tissues,       .         .  286 

63.  Section  of  spleen  in  case  of  intermittent  htematuria,  showing  great  excess 

of  blood  pigment 286 


MISCELLANEOUS    AFFECTIONS 


OF     THE 


KIDNEYS    AND    URINE. 


CHAPTER  I. 


ABSCESS,   OE   CIECUMSCRTBED   INFLAMMATION    OF     THE 

KIDNEY. 

It  is  scarcely  necessary  in  these  days  to  insist  upon  the  obvious  dis- 
tinction between  abscess  originating  within  the  renal  substance,  which  is 
now  in  question,  and  suppuration  of  the  renal  cavity,  or  suppurative  pye- 
litis, which  will  find  mention  elsewhere;  although  among  the  older 
writers  the  term  "  abscess  of  the  kidney  "  was  applied  indiscriminately  to 
both,  and  much  of  their  recorded  experience  thus  rendered  indefinite. 

Suppurative  or  phlegmonous  nephritis  has  its  origin  in  the  blood- 
vessels and  intertubalar  tissues  of  the  kidney,  and  is  circumscribed  to 
one  or  many  points. 

It  may  be  produced  by  the  following  causes: 

1.  Blows  and  mechanical  injuries. 

2.  Irritant  drugs. 

3.  PyaBmia. 

4.  Morbid  states  of  the  urine,  such  as  are  especially  associated  with 
cystitis. 

5.  The  formation  of  tubercle  and  possibly  other  growths  in  the  kid- 
ney. 

For  the  latter  conditions  I  must  refer  to  the  section  upon  tubercle. 

Abscess  of  Kidney  from  External  Violence. 

Such  immediate  effects  of  external  injures  as  Avounds,  rents,  and 
bruises  of  the  kidney  do  not  come  within  the  experience  of  the  physi- 
cian, and  ai'e  not  included  in  the  present  work. 

Though  it  is  not  uncommon  for  the  kidney  to  be  broken  or  torn,  life 
under  such  circumstances  being  endangered  by  haematuria  and  other  im- 
mediate consequences  of  the  accident,  it  would  seem  that  there  is  but  lit- 
tle risk  of  any  induced  inflammation  of  the  renal  substance.  The  rent 
is  soldered  up  with  coagulum,  and  if  the  patient  outlive  other  results  of 
1 


2  ABSCESS    OF   THE    KIDNEY. 

the  accident,  effective  union  generally  takes  place,  as  in  an  instance  re- 
lated at  p.  3. 

Suppurative  inflammation  in  the  substance  or  on  the  surface  of  the 
kidney/as  the  result  of  a  blow  or  fall,  is  accordingly  rare.  Frequently 
as  suppuration  occurs  in  the  kidney  under  other  circumstances,  traumatic 
abscess  is  a  pathological  curiosity.'  One  case  and  one  only  has  been  de- 
scribed at  St.  George's  Hospital,  as  the  result  of  an  injury,  and  even  that 
presented  on  posl-niortefn  examination  an  equivocal  resemblance  to  pye- 
litis. The  pus  escaped  with  the  urine,  and  it  is  not  clear  that  it  had  not 
originated  in  the  pelvis  ratlier  than  in  the  substance. 

The  association  of  abscess  with  laceration  or  contusion  of  the  renal 
substance  is,  however,  distinctly  seen  in  the  following  case  which  oc- 
curred in  the  practice  of  the  late  Dr.  Bright.  The  prejiaration  Avliich  is 
preserved  at  Guy's  Hospital  shows  the  result  of  a  severe  blow  upon  the 
loins,  inflicted  nine  months  before  death.  The  capsule  of  the  kidney, 
thickened  in  some  places  to  half  an  inch,  is  separated  from  the  surface 
of  the  gland  by  an  irregular  mass  of  mingled  coagulum  and  pus. 

This  is  the  only  preparation  I  know  of  in  the  pathological  museums 
of  London  which  supplies  an  example  of  a  renal  abscess  resulting  from  an 
external  injury,  though  several  cases  could  be  brought  together  from 
other  sources.  Tiie  most  frequent  form  appears  to  be  the  infiltration  of 
part  of  the  renal  substances  by  pus  and  blood,  possibly  so  as  to  convert 
it  into  a  sanious  pulp.  Such  an  instance  is  related  by  Siebert."  A  man 
jumped  from  a  moving  train,  was  turned  over  several  times,  thrown  to  a 
considerable  distance,  and  found  upon  his  back.  The  urine  was  after- 
wards scanty,  bloody,  and  albuminous.  After  his  death,  which  occurred 
in  six  weeks,  the  substance  of  both  kidneys  was  found  to  be  reduced  to  a 
pulpy,  bloody  mass,  from  which  could  be  squeezed  the  detritus  into  which 
the  greater  part  of  both  kidneys  had  been  transformed. 

Tiie  following  case  from  Rayer  appears  also  to  be  unequivocal' . 

Citizen  A.,  aged  thirty,  was  serving,  in  the  month  Prairial,  on  board  a  ship 
apparently  in  tlie  Revolutionary  service.  He  fell  upon  a  yard  so  as  to  bruise  the 
loins,  especially  over  the  region  of  the  left  kidney.  This  was  followed  by  sharp 
and  severe  lumbar  pain,  which  persisted  in  spite  of  frequent  blood-letting.  The 
urine  became  bloody.  Febrile  disturbance  then  set  in.  with  which  the  urine,  which 
had  now  ceased  to  contain  blood,  became  scanty.  The  febrile  sj^mptoms  gradu- 
ally assumed  a  typhoid  type,  with  drj-ness  of  the  tongue  and  much  prostration 
and  shivering.  On  the  twelfth  day  after  the  accident,  the  urine  was  temporarily 
suppressed,  the  secretion  re-appearing  on  the  day  following  with  a  large  discharge 
of  pus.  The  pain  was  now  relieved,  but  the  prostration  continued,  and  he  sank 
a  fortnight  after  he  fell. 

After  death  a  large  quantity  of  bloody  serum  was  found  in  the  abdominal  cav- 
ity. The  left  kidney  was  IJabby  exterimlly,  and  was  internally  extensively 
broken  up  ;  it  contained  about  an  ounce  of  fcBtid  sanious  pus. 

Acute  suppuration  connected  with  the  kidney  appears  to  be  generally  attended 
with  febrile  symptoms,  sometimes  of  a  typhoid  type;  it  is  probable,  however, 
that  in  this  case  the  prostration  was  intensitied  by  the  blood-letting  which  was  so 
remorselessly  practised. 

From  the  preceding  cases  we  may  learn  that,  though  an  event  of 
great  comparative  iufrequency,  abscess  of  the  kidney  may  result  from  a 

'  This  statement  is  not  meant  to  include  the  caseous  or  tuberculous  change 
which  may  follow  a  blow  or  fall  and  end  in  abscess  or  excavation.  A  descrip- 
tion of  this  is  to  be  found  in  Chap.  X.  of  this  part. 

'  Quoted  by  Ebstein,  Ziemssen's  Cydopcedia,  vol.  xv.  p.  547. 

'  Maladies  des  Reins,  t.  i.  p.  342. 


ABSCESS    OF    THE    KIDNEY.  3 

blow  upon  the  loins  or  hypochondrinm.  Hasmaturia  appears  to  be  gen- 
erally ]n-esent  at  the  outset,  suggesting  that  the  primary  injury  has  been 
a  hiceration  or  contusion  of  the  renal  substance.  According  to  the 
amount  of  contusion,  the  symptoms  may  take  an  acute  form  and  rapidly 
destroy  life  with  febrile  prostration,  or  the  abscess  may,  if  I  may  accept 
the  evidence  of  one  somewhat  equivocal  case,  become  clironic,  enter  the 
pelvis,  and  continue  for  a  long  time  to  discharge,  producing  the  consti- 
tutional effects  of  protracted  sui)puration.  It  is  probable  that  in  its  less 
severe  form  the  process  may  end  in  recovery. 

The  kidney  may  be  more  or  less  bruised  or  contused  by  a  blow,  and 
quickly  recover  from  the  disturbance  of  function  which  has  been  so  pro- 
duced. In  the  following  case  there  was  evidence  that  an  injury  of  the 
kidney  produced  a  temporary  conditio]i  of  albuminuria. 

A  boy,  ten  years  of  age,  came  under  my  care  at  the  Hospital  for  Sick  Children, 
He  had  while  at  play  fallen  with  liis  belly  upon  the  upturned  leg  of  a  stool,  and 
had  made  a  bruise  just  in  front  of  the  left  anterior  superior  spine  of  the  ilium. 
Immediatelj'  after  the  fall  he  becaiue  sick  and  prostrate,  and  complained  of  ab- 
dominal pain.  The  next  day,  when  brought  to  the  hospital,  he  had  signs  of  peri- 
tonitis, the  belly  Avas  tympanitic  and  excessively  tender,  he  lay,  intolerant  of 
movement,  on  the  left  side  with  tlie  legs  drawn  up,  the  breathing  was  entirely 
thoracic,  and  was  accompanied  with  catching  pain.  He  had  had  diarrhoea,  with 
much  flatus,  and  liquid  motions,  which  he  said  felt  like  boiling  water,  and  there 
was  much  febrile  disturbance.  The  urine  was  scanty,  free  from  blood,  but  highly 
albuminous,  the  clot  reaching  to  about  a  fourth.  He  had  small  repeated  doses  of 
opium,  and  warm  applications  externally,  and  in  three  days  the  acuteness  of  the 
symptoms  had  so  far  abated  as  to  give  promise  of  recovery.  On  the  fifth  day  his 
progress  was  interrupted  by  an  attack  of  acute  pain  accompanied  by  pleural  fric- 
tion in  the  lower  region  of  the  right  chest,  but  this  soon  passed  off,  and  he  grad- 
ually i-ecovered  his  health,  the  urine  slowly  a^pproaching  its  natural  abundance, 
the  albumin  steadily  diminisliing  ;  though,  when  he  left  the  hospital  for  the  con- 
valescent establishment,  eighteen  days  after  admission,  a  trace  could  still  be  de- 
tected by  careful  examination.     He  had  lost  all  other  results  of  the  accident. 

The  injury  had  evidenth'  set  up  peritonitis,  and  had  so  bruised  the  left  kidney 
as  to  occasion  a  temporary  condition  of  nephritis.  The  attack  of  pleurisy  on  the 
right  side,  remote  from  the  blow,  was  more  doubtful  in  its  source,  and  it  remains 
uncertain  whether  it  is  to  be  accounted  for  by  the  direct  effect  of  the  blow,  or 
whether  it  was  produced  indirectly  as  a  consequence  of  the  renal  disturbance. 

The  following  case  is  of  interest,  as  bearing  upon  the  remote  conse- 
quences of  renal  injuries,  though  only  indirectly  connected  with  the  sub- 
ject of  traumatic  abscess. 

Laceration  of  a  kidney  previoiisly  diseased,  hcematuria  and  collapse,  apparent 
recovery.  Death,  after  the  lapse  of  eighteen  months,  from  granular  degenera- 
tion.    Obstruction  by  coagulum  of  injured  kidney. 

A  groom,  thirty-five  years  of  age,  was  brought  into  St.  George's  Hospital,  hav- 
ing received  a  kick  from  a  horse  which  broke  his  arm,  and  severely  bruised  the 
right  hypochondrium.  The  accident  was  followed  by  extreme  collapse,  with  the 
effusion  of  fluid,  at  first  thought  to  be  blood,  but  probably  serum,  the  result  of 
peritonitis,  into  the  abdominal  cavity.  He  had  haematuria,  at  first  copious, 
but  which  lasted  for  only  two  days.  He  lay  for  some  time  in  extreme  peril' 
but  at  the  end  of  seven  weeks  he  had  so  far  recovered  as  to  be  able  to  leave  the 
hospital. 

Eighteen  months  after  the  accident  he  was  recognized  in  a  medical  ward, 
where  the  case  canae  under  my  notice  as  medical  registrar. 

It  appeared  that  he  had  had  his  ordinary  health  from  the  time  he  went  out 
until  six  weeks  before  his  re-admission,  when  he  became  oedematous.  It  was 
learned,  however,  that  for  about  two  years  (commencing  apparently  before  the 
accident)  he  had  been  liable  to  pain  in  the  loins,  and  that  the  ui-ine  had  been  in- 
creased in  quantity  and  frequency. 

On  examination  the  urine  proved  to  be  pale,  copious,  albuminous  to  a  third,  to 


4  ABSCESS    OF    THE    KIDNEY. 

have  a  specific  gravity  of  1.016,  and  to  contain  many  coarse  granular  and  some 
transparent  casts.  It  was  concluded  from  tliese  circumstances,  as  well  as  from 
his  worn,  sallow  asi)ect,  that  tlie  kidneys  were  the  subject  of  gi-anular  degenera- 
tion. He  liad  much  dithculty  of  breathing,  coarse  moist  sounds  being  heard  at 
the  lower  part  of  both  lungs,  and  he  sank  a  week  after  admission. 

The  pust-inorteni  examination  was  made  by  Mr.  Holmes,  •who  has  published 
the  particulars  in  the  '•  Pathological  Transactions  "  for  1859-60. 

Both  kidneys  were  small,  granular,  and  full  of  cysts,  giving  evidence  of  a 
state  of  chronic  disease  which  had  evidently  existed  before  the  accident.  The 
cellular  tissue  around  the  right  kidney  was  much  consolidated,  and  on  making  a 
section  of  the  gland  a  large  clot  of  blood  was  seen  to  occupy  its  pelvis  and  interior, 
communicating  also  with  the  exterior,  where  a  considerable  quantity  lay  in  the 
sub-peritoneal  cellular  tissue.  The  line  of  rupture  could  be  faintly  traced  through 
the  substance  of  the  gland.  The  ureter  was  completely  impervious,  being  blocked 
up  by  coagulum.  Numerous  old  adhesions  united  the  right  lobe  of  the  liver  to 
the  diaphragm,  probabl}^  marking  the  situation  of  the  inflammation  which 
caused  the  effusion  of  peritoneal  fluid. 

The  lungs  were  much  congested,  their  hinder  and  lower  parts  sinking  in 
water.     The  heart  was  much  hypertrophied,  the  valves  natural. 

In  the  extent  of  the  laceration,  whicli  passed  from  the  pelvis  to  the  capsule, 
and  its  complete  closure,  the  case  is  of  interest  as  showing  the  great  power  of 
liealing  possessed  by  the  kidney.  The  recovery  from  the  rapid  and  total  obstruc- 
tion of  the  excreting  channels  of  the  one  kidnej'  is  the  more  striking  when  we 
consider  that  the  sole  remaining  kidney  was  probably  at  that  time  the  subject  of 
gramilar  degeneration,  on  which  account,  as  we  may  presume,  it  was  incapable 
of  the  hypertrophy  which  occurs  when  increased  duty  is  thrown  upon  a  healthy 
kidney.  The  patient  appears  to  have  pursued  his  calling  for  a  year,  thinking 
himself  well,  though  practically  reduced  to  one  kidney  and  that  one  diseased. 
When  death  occurred  it  was  the  result  of  the  progressive  disease  in  the  uninjured 
kidney;  had  that  been  sound  it  is  probable  that  the  man  would  have  been  little 
the  worse  for  the  misadventure  by  which  he  was  suddenly  deprived  of  one-half  of 
his  renal  structures. 

The  treatment  of  traumatic  abscess  of  the  kidney  is  negative;  we 
have  no  encouragement  to  use  any  measures  but  rest  and  time,  having 
regard  to  tiie  constitutional  state  of  the  patient  and  liis  temporary  symp- 
toms. The  kidneys,  as  I  htive  often  seen,  may  be  punctured  with  the  as- 
pirator without  fear,  but  sucli  abscess  as  results  from  injury  is  seldom 
definite  enough  to  admit  of  relief  by  such  means. 

Irritant  Drugs  as  Causes  of  Renal  Abscess. 

Abiscess  of  the  kidney  has  been  known  to  result  from  cantharides. 
The  state  of  kidney  usually  produced  by  this  irritant  is  one  of  acute  tu- 
bal inflammation,  and  as  such  has  been  considered  already;  but  it  must 
be  mentioned,  in  connection  with  abscess  of  the  kidney,  that  it  may  pos- 
sibly have  this  origin. 

In  the  Museum  of  the  College  of  Surgeons  is  a  kidney  which  is  al- 
most completely  destroyed  by  diffuse  su])puration.  Pus  is  extensively 
diffused  through  the  cortex,  and  between  it  and  the  capsule;  the  surface 
of  the  kidney  is  covered  with  siireds  of  its  own  broken  tissue,  and  the 
substance  is  excavated  by  a  ragged  abscess-cavity. 

"  This  was  obtained  from  the  body  of  a  man  sixty  years  of  age,  to  whom 
tincture  of  cantharides  had  been  given  for  incontinence  of  urine  conse- 
quent on  retention.  The  medicine  produced  extreme  pain,  both  of  the 
bladder  and  kidneys,  and  retention,  which  lasted  two  days.  When  the 
urine  was  drawn  off,  it  was  mixed  with  blood  and  pus,  and  foetid.  All 
power  over  the  bladder  was  lost,  and  the  patient,  scarcely  relieved  of  his 
sufferings,  died  in  tiiree  weeks.     The  prostate  was  much  enlarged.     The 


ABSCESS    OF    THE    KIDNEY.  & 

mucous  membrane  of  the  urethra  was  covered  with  lymph;  that  of  the 
bladder  was  sloughing."  ' 

Other  examples  are  known  of  suppurative  inflammation  of  the  kid- 
ney from  the  same  cause.  Cantharides  was  formerly  extensively  given 
in  cases  of  paralysis  of  the  bladder  connected  with  paraplegia,  and  oppor- 
tunities of  noting  the  characters  of  the  consequent  inflammation  Avere  of 
occasional  occurrence.  The  pelvis  and  urinary  membrane  were  affected 
very  extensively,  and  in  some  cases  covered  with  a  membranous  exuda- 
tion. 

Pyemic  Abscess. 

Pyaemia  more  often  calls  for  attention  as  a  general  condition  than  as 
affecting  any  organ  in  particular.  The  renal  localization,  much  as  it 
may  aggravate  the  condition  of  the  patient,  escapes  notice  during  life 
amid  the  other  disturbances  of  pyaemia  so  often  that  it  is  only  in  excep- 
tional instances  that  it  acquires  clinical  interest. 

The  morbid  appearances  characteristic  of  pyaemia  as  it  affects  the  kid- 
ney are  as  follows:  At  the  earliest  stage  at  wiiich  the  results  can  be  de- 
tected by  the  naked  eye,  the  kidneys,  both  of  which  are  generally  affected 
at  the  same  time  and  in  a  similar  manner,  show  on  their  surfaces  and  in 
their  substance  minute  scattered  patches  of  injected  vessels.  Later,  each 
patch  displays  in  its  centre  a  white  speck,  which  is  at  first  hard,  but  as 
it  increases  in  size  gradually  liquefies,  the  softening  beginning  at  the 
centre,  until  it  is  converted  into  a  minute  abscess  surrounded  by  injected 
tissue.  These  abscesses  are  often  plentifully  scattered  through  the  kid- 
ney, the  cones  usually  containing  more  of  them  than  the  cortex.  They 
are  mostly  of  small  size,  seldom  as  large  as  a  nut,  generally  comparable, 
when  seen  in  circular  outline,  with  peas,  mustard-seeds,  or  small  shot. 
They  are  usually,  however,  elongated,  so  as  to  present  a  circular  outline  only 
towai'ds  the  surface  of  the  organ.  In  the  cones  they  stretch  in  the  direc- 
tion of  the  tubes  and  vessels  of  which  the  cones  consists.  Sometimes  sev- 
eral can  be  seen  in  company,  either  distinct  or  more  or  less  confluent^ 
radiating  through  both  medullary  and  cortical  tissue,  and  impinging  upon 
the  surface,  where  the  circular  base  of  the  abscess  appears  as  a  pustule 
underneath  the  capsule. 

On  the  surface  of  the  organ  the  abscesses  may  be  thickly  or  sparsely 
sown.  They  project  from  the  surface  like  the  eruption  of  small-pox,  of 
which  the  surface  of  the  kidney  is  under  these  circumstances  often  sug- 
gestive. Sometimes  larger  abscesses  form  bosses  on  the  surface  of  con- 
siderable size  and  prominence.  The  surface  of  the  gland  around  and 
between  the  points  of  suppuration  is  unnaturally  injected,  each  pustule 
being  sometimes  surrounded  by  a  bright  zone  of  distended  vessels. 

The  tissue  of  the  organ  is  throughout  more  or  less  overloaded  with 
blood,  and  often  has  the  coarse  texture  and  indistinctness  of  structure 
which  results  from  epithelial  accumulation. 

Analyzing  these  obvious  morbid  appearances  with  the  microscope,  I 
have  found  them  to  consist  of  the  following  elementary  changes. 

The  columnar  and  wedge-like  disposition  of  the  abscesses,  as  evident  to 
the  naked  eye,  is  suggestive  of  their  connection  with  blood-vessels,  a  con- 
nection which  is  at  once  evident  on  microscopic  examination. 

Many  of  the  vessels  of  the  kidney  are  occupied,  often  to  distention, 

'  See  Catalogue  of  the  College  of  Surgeons. 


6  ABSCESS    OF    THE    KIDNEY. 

with  a  dirty  white  material,  which  appears  to  be  morbid  coagulum.  This 
is  sometimes  seen  in  tlie  larger  arteries,  but  is  found  in  the  greatest 
abundance  in  the  straight  vessels  of  the  cones,  wliich  are  often  swollen 
to  varicosity.  Loss  frequently  the  peculiar  discoloration  is  found  in  the 
Malpighian  bodies  and  in  the  intertubular  capillaries.  Thus  it  would  seem 
that  the  arteries  have  been  injected  with  a  material  different  from  their 
natural  contents,  most  of  whicii  is  arrested  in  the  small  arterial  branches, 
comparatively  little  reaching  tlie  vessels  of  the  capillary  size.  It  will 
be  remembered  that,  according  to  the  observations  of  Virchow,  many  of 
the  straiglit  arteries  of  the  cones,  whicli  especially  are  tlie  seat  of  the 
peculiar  obstruction,  come  directly  from  the  renal  artery,  some  only  being 
derived  from  the  Malpighian  bodies.  The  contents  of  the  arteries,  there- 
fore, early  roach  the  cones. 

The  next  stop  in  tlie  morbid  process  is  the  appearance  among  the  ob- 
Etructed  vessels  of  rounded  collections  of  pus-corpuscles.  These  some- 
times interrupt  the  course  of  a  plugged  vessel,  as  if  formed  at  its  expense; 
sometimes  they  appear  among  and  between  distended  vessels,  forcibly 
thrusting  aside  the  vessels,  tubes,  and  all  tiie  renal  structures.  These 
abscesses  begin  as  small  masses  of  coherent  corpuscles,  which  often  show 
in  their  centre  small  masses  of  the  same  matter  as  obstructs  the  vessels, 
suggesting  their  origin  in  the  bursting  of  a  vessel  and  the  escape  of  part 
of  its  contents  into  the  tissue  to  act  as  an  irritant,  and  becomes  a  focus 
of  suppuration. 

The  corpuscles  rapidly  multiiily,  and  the  abscess  increases,  pushing 
aside  the  tissue  as  it  swells,  until  at  last  it  assumes  the  character  of  a  col- 
lection of  liquid  pus  lying  in  a  cavity  bounded  by  condensed  kidney- 
structure.  Whatever  the  size  of  the  pyaemic  formations  may  be,  whether 
invisible  to  the  naked  eye  or  as  large  as  a  marble,  their  anatomy  is  essen- 
tially the  same.  They  are  not  made  at  the  expense  of  the  secreting 
structures,  but  are  intrusions  between  them.  They  occur  especially  in 
connection  with  the  straight  vessels  of  the  cones,  upon  which  little 
globular  collections  arc  often  ranged  like  beads  upon  a  string.  Where 
the  vessels  extend  from  the  cones  to  the  cortex,  the  formations  are  apt  to 
follow.  Their  situation  is  determined  by  the  position  of  the  distended 
vessels,  and  the  only  doubt  whicli  attends  their  origin  is  whether  the 
vessel  actually  bursts,  or  without  rupture  permits  the  migration  of  its 
morbid  contents  through  tlie  wall.  The  microscopic  appearances,  as  I 
have  described  them,  are  suggestive  of  rapture,  the  escaped  morbid  con- 
tents acting  as  the  excitant  of  the  cell  growth  around,  which  eventually 
breaks  down  into  liquid  pus.  These  details  are  perhaps  useful  as  bearing 
]io  less  upon  the  general  pathology  of  pysemia  than  upon  the  particular 
affection  of  the  kidney.  They  support  the  conclusions  formed  on  differ- 
ijut  grounds  by  Mr.  Henry  Lee,  and  corroborated  by  other  observers. 
Pyaemia  is  simply  embolism  in  which  thecoagula  distributed  are  morbidly 
irritating  to  the  tissue,  and  tend  by  their  contact  to  excite  the  produc- 
tion of  pus.  AVhether  their  irritating  quality  is  due  to  the  presence  of 
bacteria  or  to  the  admixture  of  any  other  morbid  product,  the  pi-ocess  is 
clear  in  this  as  in  other  organs.  Poisoned  einb(jli,  whether  derived  from 
a  vein  communicating  with  a  wound  or  elsewhere,  are  let  loose  into  the 
circulation,  and  finally  distributed  by  the  arteries,  jiroducing  scattered 
abscesses  such  as  have  been  described,  in  positions  determined  by  the 
source  of  the  infection  and  the  course  of  the  blood. 

The  clinical  results  of  the  renal  implication  of  jiyaemia  are  of  only 
subordinate  importance.     Often  as  the  kidney  is  found' to  be  affected  after 


ABCESS    OF    THE    KIDNEY.  7 

death,  it  is  comparatively  seldom  that  this  complication  attracts  notice 
during  life.  It  may  result  from  any  of  the  causes  to  which  pyaemia  aris- 
ing in  connection  with  the  systemic  as  distinguished  from  the  portal  vessels 
is  due.  In  the  cases  I  have  referred  to  as  the  basis  of  this  description, 
the  disorder  was  traced  to  the  following  causes:  Diseases  of  bones  and 
joints;  osteomyelitis;  jieriostitis;  suppurating  bursa?;  senile  gangrene; 
ulceration  of  cheek;  diffuse  suppuration  after  a  bruise;  amputation  of 
limbs,  and  other  surgical  operations;  and  accidental  wounds.  In  short, 
whatever  be  the  source  of  a  general  pyaemic  infection,  the  kidney  runs 
its  chance  of  attack,  though  affected  far  less  frequently  than  the  lungs, 
which  from  their  anatomical  relations  are  necessarily  the  first  recipients 
of  the  poisoned  current. 

It  does  not  consist  with  my  present  purpose  to  discuss  the  general 
symptoms  of  pyaemia — these,  the  rigors,  the  febrile  prostration,  the 
altered  color  of  the  skin,  and  the  multiple  abscesses,  belong  to  the  do- 
main of  surgery.  The  only  signs  of  disease  which  point  es])ecially  to  the 
Icidneys  are  shown  by  the  urine,  which  is  apt  to  become  albuminous, 
scanty,  dark  in  color,  possibly  lithatic,  and  to  abound  with  tube-casts  of 
various  kinds — epithelial,  granular,  and  hyaline — while  in  some  cases 
they  characteristically  imbed  pus-corpuscles,  while  others,  unattached, 
may  be  also  discoverable  with  the  microscope,  though  there  is  no  bulky 
deposit  of  this  nature.  Casts  are  more  regularly  found  with  renal 
pyaemia,  in  which  the  urine  is  usually  acid,  than  with  the  form  of  dis- 
seminated suppuration  to  be  next  described,  in  which  the  urine  is  almost 
constantly  alkaline,  and  thus  a  solvent  for  these  products. 

Though  the  pyaemic  deposits  are  necessarily  intertubal,  the  neigh- 
boring tubes  suffer  by  contact,  as  is  easily  seen  by  the  abundance  of 
plugged  tubes  around  a  pyaemic  focus. 

Pyaemie  suppuration,  beginning  Avith  the  kidney,  may  transgress  its 
limits  and  become  perinephritic,  or  even  present  itself  as  a  suj^erficial 
tumor.  A  woman  had  an  abscess  of  the  leg  opened  in  St.  George's  Hos- 
pital; it  closed,  and  she  went  away,  but  shortly  returned  with  signs  of 
irritation  about  the  place  of  the  abscess,  which  was  accordingly  reopened. 
Then  ensued  rigors,  sweating,  and  pneumonia,  in  addition  to  which  a 
rounded  swelling  of  the  extent  of  the  palm  of  the  hand  showed  itself 
under  the  last  rib  on  the  right  side.  The  urine  was  now  highly  albu- 
minous, lithatic,  and  scanty.  She  fell  into  a  condition  of  febrile  pi'os- 
tration,  with  sordes  on  the  lips  and  much  dyspnoea,  and  thus  died,  seven 
weeks  after  the  reopening  of  the  abscess,  three  after  the  detection  of  the 
pneumonia.  The  external  swelling  was  caused  by  a  large  collection  of 
jDUs  which  lay  between  the  liver  and  the  right  kidney,  in  the  substance 
of  which  it  had  apparently  taken  its  origin,  lifting  the  capsule  from  the 
posterior  surface  of  the  organ.  The  abscess  extended  widely  behind  the 
peritoneum,  in  contact  with  the  sacrum  and  ilium,  both  of  which  were 
healthy,  and  had  penetrated  for  some  distance  down  the  psoas  muscle  in 
the  course  of  the  nerves.  Both  kidneys  were  occupied,  particularly  in 
their  cones,  with  recent  and  caseating  pyaemic  abscesses. 

Tliere  were  extensive  pyemic  formations  in  the  lungs  and  heart. 
The  source  of  the  disease  jjroved  to  be  a  sinus  between  the  tibia  and 
fibula,  in  which  was  found  a  strip  of  discolored  oiled  silk  four  inches 
long,  which  had  been  lost  in  the  abscess. 

The  treatment  of  renal  pyaemia  is  not  particular  to  the  kidney,  but 
general  to  the  system,  and  therefore  not  within  the  scope  of  this  work. 


ABSCESS    OF    THK    KIDNEY. 


The  Surgical-Kidney;  or  the  Kidxey  of    Locally  Dissemi- 
nated Suppuration.' 

The  peculiar  suppurative  condition  which  is  often  spoken  of  as  the 
surgical  kidney  is  marked  by  abscesses  scattered  like  those  of  pyaemia 
through  the  renal  structure,  but  seldom  involving  other  j^arts  of  the  body. 
It  has  its  origin  in  the  presence  of  unhealthy  urine  in  the  bladder  and 
absorption  by  the  renal  vessels.  I  ventured  to  propose  the  term  urisep- 
tic  as  descriptive  of  the  invariable  cause  of  this  variety  of  renal  suppura- 
tion, but  possibly  the  term  '  surgical  kidney,^  though  it  may  throw 
blame  with  too  little  discrimination  upon  surgeons  and  their  proceedings, 
may  have  become  too  well  known  to  permit  of  any  change  in  its  designa- 
tion. 

Of  all  renal  disorders,  next  to  the  varieties  of  albuminuria,  this  is  the 
most  destructive  to  life.  It  may  almost  be  said  to  form  the  natural  ter- 
mination of  stricture  of  the  urethra,  and  is  the  especial  danger  which 
attends  the  use  of  the  catheter  and  litiiotrite.  Tiie  attention  which  has 
been  directed  to  this  affection,  however,  is  scarcely  commensurate  with 
its  importance. 

The  change  usually  affects  both  kidneys,  though  in  rare  cases  it  is 
limited  to  one.  Tlie  pelves  arc  generally  more  or  less  dilated,  and  give 
evidence  of  inflammatory  action  in  tlie  state  of  their  mucous  mem- 
brane. This  is  commonly  injected,  often  tliickened,  creamy,  and  sup- 
liurating,  frequently  encrusted  with  pliosphatic  salts,  and  not  seldom 
jjartially  or  superficially  sloughing.  The  kidney,  if  the  primary  obstruc- 
tion be,  as  it  generally  is,  of  considerable  standing,  shows  the  results  of 
wasting  pressure  and  chronic  vascular  disturbance.  The  cortex  is  thinned, 
the  ca})sule  is  thickened,  and  holds  witli  unnatural  tenacity  both  to  the 
glandular  surface  and  more  closely  still  to  the  surrounding  fat,  which  it- 
self is  often  markedly  increased,  probably  in  consequence  of  undue  vas- 
cular injection  around  the  kidneys.  Disseminate  renal  suppuration  may, 
liowever,  take  place  without  any  preceding  chronic  change,  though  in- 
flammation or  congestion  of  some  part  of  the  urinary  mucous  membrane, 
possibly  of  recent  date,  appears  to  be  an  invariable  antecedent. 

The  glandular  condition  nearly  resembles  to  the  naked  eye,  and  also, 
as  Avill  presently  appear,  in  more  minute  respects,  the  renal  manifestation 
of  general  pygemia.  The  kidney  becomes  swollen  and  full  of  blood, 
much  of  which  remains  fluid  after  death,  though  some  vessels  contain 
clot  evidently  of  ante-mortem  origin.  The  tissue  is  variegateil  with 
blotches  and  streaks  of  intense  injection  ;  it  is  soft,  friable,  discolored, 
and  prone  to  decomposition.  • 

The  cones  usually  display  to  the  scrutinizing  eye  sharply  defined 
white  lines,  which  start  from  the  tips  of  the  mammillary  processes  in  the 
pelvic  cavity  and  pass  into  or  through  the  cones  in  the  direction  of  their 
striation.  These  streaks  look  like,  what  indeed  they  are,  distended 
tubes,  and  are  important  witnesses  of  perverted  action.  Close  to  them 
swollen  blood-vessels  are  often  conspicuous. 

'  The  publication  of  a  considerable  portion  of  the  section  on  the  surgical  kid- 
ney was  anticipated  by  its  appearance  as  a  paper  in  the  Medico-Chirurgical 
Transactions  for  1873,  drawn  forth  by  the  interest  which  was  directed  upon  the 
disease  by  the  death  from  it  of  the  Emperor  Napoleon  after  lithotrity.  The  de- 
scription now  takes  the  place  for  which  it  was  originally  designed. 


ABSCESS    OF    THE    KIDNEY. 


9 


Next,  or  possibly  without  such  evidences  of  chronic  change  as  the 
swollen  tubes  give,  appear  small,  softly  defined,  fawn-colored  patches 
which  streak  the  cortex  from  cones  to  capsule,  or  take  the  shape  of 
wedges  with  the  base  against  the  capsule,  the  point  entering  tlie  medul- 
lary tissue.  These  are  at  first  scarcely  less  hard  though  more  friable 
than  the  natural  substance  of  the  organ.  They  are  surrounded  and  in- 
termingled with  vascularity.  As  the  disease  progresses  they  become 
large,  irregular,  and  confluent,  soften  in  their  centres  into  ordinary 
liquid  pus,  and  finally  take  the  shape  of  scattered  abscesses,  varying 
from  mere  points  up  to  the  size  of  peas,  or  even  larger.  These  are 
often  thickly  sprinkled  through  the  gland,  occupying  the  cones,  where 
they  keep  more  or  less  of  a  linear  arrangement,  and  are  less  regularly 
but  more  numerously  distributed  through  the  cortex.     They  appear  on 


'-S^llit.J ,>,,.i  ,.£..!  !,,:, 


.1'.     I 


'i      iMlH  ,1    9      UA 


,\.  \y 


straight  tubes  as  they  approach  their  exit  dilated  by  backward  pressure. 


•the  surface  sometimes  as  purple  blotches  in  which  suppurative  centres  can 
be  seen,  or  as  discrete  or  confluent  jiustules,  often  nearly  resembling  a 
cutaneous  pustular  eruption. 

With  this  condition  the  microscope  shows  more  or  less  dilatation  of 
the  straight  tubes,  distention  or  morbid  occupation  of  the  associated 
blood-vessels,  and  disseminated  intertubular  suppuration,  the  distribu- 
tion of  which  is  regulated  by  the  course  of  the  veins. 

Passing  to  detail,  and  taking  the  straight  tubes  first  as  the  parts  of 
the  organ  first  affected,  these  as  they  converge  upon  their  outlets  are 
often  strikingly  dilated  apparently  from  the  backward  pressure  of  the 
retained  urine.  The  dilatation  is  irregular,  widening  the  cylindrical 
shape  of  the  tubes  or  converting  tlicm  into  ovoid,  globular,  or  shapeless 


10  ABSCESS    OF   THE    KIDNEY. 

cavities.  They  are  variously  occupied  by  saline  matter,  purulent  secre- 
tion, fibrin,  or  epithelial  growth.  The  straight  tubes,  thus  stretched 
and  filled,  form  tlie  wliite  lines  which  are  evident  to  the  naked  eye.  The 
change  does  not  extend  to  the  convoluted  tubes,  which  remain  for  the 
most  part  natural. 

The  veins,  wliich  appear  to  be  next  involved  in  the  disease,  are  gen- 
erally distended  with  blood.  The  straight  veins  of  tlie  cones  often  dis- 
play in  section  a  partial  distention  which  is  probably  the  result  of  coagu- 
lation which  has  occurred  during  life. 

The  larger  veins  of  the  cortex  arc  often  similarly  filled,  and  it  some- 
times liappens  tliat  the  arteries  which  pass  in  companionsliip  with  them 
are  likewise  jjcrmanently  occupied.  As  a  general  rule,  however,  the 
arteries  are  natural,  as  also  are  the  Malpighia'n  vessels. 

The  venous  position  of  the  clot  in  the  condition  under  consideration 
differs  from  the  similar  result  of  ordinary  pyaemia,  in  that  the  obstruction 
there  is  essentially  ai'terial. 

The  third  stage  of  the  disease  is  the  scattered  suppuration  which  is 


/ 


jo 

I 


•^ 


'I 

''I, 
1 


Irritative  plugs  in  small  vessels  surrounded  bj  pus  corpuscles— from  cone. 

the  most  obvious  result  of  the  com]ilicated  process.  The  disseminated 
abscesses,  or  regions  of  cellular  infiltration  antecedent  to  abscesses,  are 
intertubular,  and  have  relation  to  the  course  of  the  veins.  Cells  gather 
at  isolated  spots,  sometimes  obviously  accumulated  around  a  minute  dis- 
tended vessel.  Occasionally  the  new  formation  oversiireads  considerable 
districts,  insinuating  itself  more  or  less  evenly  between  the  tubes,  its 
vascular  origin  being  chiefly  evinced  by  its  obvious  intertubular  position. 
The  Malpighian  bodies  remain  unalfected  by  the  disease,  though  the  ad- 
ventitious corpuscular  formation  often  collects  abundantly  outside  them. 
The  convoluted  tubes  are  generally  clear,  though  where  they  cross  the 
districts  of  infiltration  their  epithelium  is  sometimes  superabundant,  and 
sometimes    they    appear    to    be    encroached     upon,    or    confused    by. 


ABSCESS    OT   THE    KIDNEY.  11 

the  cellular  formation  around  them.     They  are  sometimes  displaced  or 
compressed. 

Taking  the  structural  changes  in  their  mutual  relation,  the  dilatation 
of  the  tubular  exits,  tlie  morbid  occupation  of  the  veins,  and  the  general 
absence  of  signs  of  tubal  inflammation,  the  nature  of  the  process  is 
clear. 

The  disorder  has  its  origin  in  the  regurgitation  of  urine  charged 
with  morbific  products.  This,  forced  backwards  by  the  retention  gen- 
eral in  these  cases,  distends  or  occupies  the  straight  ducts.  Thence  by 
transudation,  or  similarly,  it  enters  the  neighboring  blood-vessels,  and 
charges  them  with  an  infection  resembling  in  its  results  that  of  pyaemia. 
This  is  distributed  by  the  veins  to  the  rest  of  the  gland,  sowing  ab- 
scesses in  their  course,  and  ultimately  causing  constitutional  symptoms 
analogous  to  those  of  pyaemia  otherwise  derived. 

The  condition  of  the  kidney  may  be  described  as  one  of  pyaemia 
arising  within  itself.  It  has  a  close  general  resemblance  to  that  caused 
by  a  distant  infection,  differing  from  it  in  the  usual  dilatation  of  the 
urinary  outlets,  and  in  the  fact  that,  while  with  pyaemia  from  a  remote 
source  the  materies  morbi  is  necessarily  distributed  by  the  arteries,  in 
the  condition  under  discussion  it  is  scattered  by  the  veins  into  which  it 
was  first  received. 

The  disorder  in  its  frequency  and  fatality  has  great  practical  impor- 
tance. Inflammation  of  the  bladder,  or  of  the  pelvis  of  the  kidney,  either 
as  antecedent  to  the  change,  or  associated  with  it,  is  so  invariably  present 
as  to  give  a  seeming  warrant  to  the  old  view  which  regarded  the  disease 
as  a  mere  extension  by  contiguity  of  inflammation  beginning  in  the 
urinary  cavities.  The  nature  of  the  organic  change,  however,  plainly 
declares  its  origin,  not  in  the  mere  creeping  of  inflammation  from  mem- 
brane to  gland,  but  in  the  absorption  of  morbific  matter.  Of  this  the 
urine  is  obviously  either  the  source  or  the  vehicle.  It  remains  to  inquire 
whence  and  in  what  circumstances  the  poison  is  engendered. 

To  help  in  answering  these  questions  I  have  collected  the  particulars 
of  sixty-nine  cases  of  the  disease  from  the  post-mortem  books  of  St. 
George's  Hospital.  The  following  table  shows  the  urinary  disease  upon 
which  the  suppurative  condition  of  kidney  followed: 

Disease  antecedent  to  disseminated  supjniration  of  kidney  in  sixty-nine 

cases. 

Obstacle  to  escape  j  Stricture  of  urethra, 19 

of  urine.           \  Disease  of  prostate,  enlargement,  tumor,  or  abscess,  .  12 

f  Paralysis  of  bladder  from  fracture  of  spine,        .         .  5 

I            "                "            "     disease        "          ...  3 

Loss    of    expulsive!           "               "           "         '*          of  cord,          .        .  4 

power              1            "                "            "         "          of  brain,         .         .  3 

I  •'  "         consequent     upon     exhaustion 

(_                from  disease  or  accident,          ....  2 

(  Stone  in  bladder,  no  operation 6 

Vesical  calculus.       \         "            "         lithotrilv, 6 

(         "            "         lithotoniy, 3 

r Cystitis  from  vesical  growths,  etc.,      ....  3 

•Cystitis  from  other  J  "      unexplained, 1 

causes.  )  "      from  discharge  of  lumbar  abscess  into  blad- 

t  der, 1 

Complicated. — Stone  in  kidney,  with  enlarged  prostate,      ...  1 

69 


Reaction  stated. 


12  ABSCESS    OF    THE    KIDNEY. 

I  have  next  classified  the  descriptions  of  the  urine  in  each  case.  The 
state  of  this  secretion  was  noted  in  47  of  the  number,  in  the  following 
terms: — 

State  of  the  urine  in  forty-seven  of  the  cases  previously  referred  to. 

f  Ammoniacal  or  foetid,  and   mixed  with  various  pro- 

I  ducts  of  vesical  inflammation,    .         .         .         .21 

Aniraouiacul, 1 

"<  Alkaline  .md  turbid,  or  containing  mucus,      ...  3^ 

Alkaline,  blood}-,  and  purulent 1 

Alkaline  or  "  pliosphatic," 3 

f  Rop}-,  containing  mucus,  pus,  and  blood,        ...  1 

I  Containing  mucus  and  pus, 1 

T,       ^.  ....  .^    1    I  Purulent  and  bloody, 4 

Reaction  not  stated,  j  p^jj.^,l^.jj^  -^ ^ 

I  Bloody, .4 

l_  Albuminous  and  turbid,  or  purulent,       .         .  .2 

47 

Looking  first  at  the  urine  as  directly  connected  with  the  origin  of  the 
disease,  it  appears  that  three  conditions  of  this  secretion  usually  concur — 
retention,  ammoniacal  decomposition,  and  admixture  with  the  products 
of  mucous  infiammation.  Of  these  an  essential  circumstance  aj)pears  to 
be  ammoniacal  decomposition,  which  retention  may  induce,  and  cystitis 
either  precede  or  follow.  The  urine  was  generally  foetid  and  more  or 
less  mixed  with  vesical  products,  pus,  mucus,  and  blood.  There 
is  reason  to  believe  that  it  Avas  invariably  ammoniacal.  Wherever  the 
reaction  was  stated,  it  was  persistently  alkaline  except  in  one  instance. 
In  this  exceptional  case,  the  secretion  was  alkaline  when  tlie  inception  of 
the  disease  was  declared  by  rigors,  then  for  a  short  time  acid,  and  alka- 
line again  before  death. 

In  the  cases,  comparatively  few,  in  which  the  reaction  Avas  not  stated, 
the  condition  of  retention  or  the  state  of  the  urninary  mucous  membrane 
was  generally  such  as  to  point  unmistakably  to  ammoniacal  change. 
The  simple  presence  of  pus  or  mucus  in  the  urine,  though  lasting  for 
years,  does  not  appear  to  set  up  the  renal  disorder  so  long  as  the  urine  re- 
tains its  acidity  and  resists  putrefaction. 

I  have  myself  known  no  instance  in  which  the  mischief  has  arisen 
except  in  connection  with  ammoniacal  urine. 

The  ammoniacal  change,  however,  though  it  may  arise  independently  of 
mucous  inflammation,  produces  it  so  constantly  that  the  origin  of  the 
disease  is  always  thus  complicated.  Sometimes,  as  with  stone,  the  inflam- 
mation of  the  bladder  has  led  to  the  change  in  the  urine;  sometimes,  as 
in  cases  of  paralysis,  the  change  in  the  urine  has  caused  the  inflam- 
mation of  the  bladder.  Whichever  comes  first,  so  long  as  the  necessary 
foulness  of  the  urine  is  attained,  a  condition  which  is  promoted  by  the 
admixture  of  diseased  vesical  secretion,  the  renal  suppuration  may  follow. 
AVhether  primary  or  secondary,  the  inflammation  of  the  urinary  mucous 
membrane  is  invariable.  This  is  usually  of  the  bladder,  though  the  re- 
nal change  has  been  known  to  follow  inflammation  and  retention  confined 
to  the  pelvis  caused  by  a  stone  situate  in  that  cavity. 

Passing  from  the  state  of  the  urine  to  its  clinical  antecedents,  these 
may  generally  be  stated  to  be  of  three  kinds — obstacles  to  the  escape  of 
the  urine,  loss  of  expulsive  power,  and  vesical,  or  very  rarely,  pelvic 
irritation. 


ABSCESS    OF   THE   KIDNEY.  13 

Stricture  of  the  urethra  is  of  all  causes  the  most  common,  giving  rise 
as  it  does  to  the  needful  urinary  putrefaction,  and  in  its  chronic  form 
insuring  the  dilatation  of  the  glandular  exits  which  makes  them  ready 
recipients  of  the  poison. 

Enlargement  of  the  prostate,  scarcely  less  common  as  a  cause  of  the 
disease,  acts  in  the  same  way. 

Next  in  order  of  frequency  to  such  impediments  come  the  diseases 
and  injuries  of  the  nervous  system,  by  which  the  expulsive  power  of  the 
bladder  is  destroyed.  These,  giving  rise  to  retention  and  decomposition 
of  urine,  and  its  contamination  by  the  products  of  vesical  inflammation, 
cause  changes  in  the  same  sequence  as  those  which  arise  from  stricture, 
but  more  rapid  in  progress.  The  loss  of  vesical  innervation  in  these 
cases  hastens  the  disorganization  of  the  mucous  membrane,  which  gives 
the  extreme  foulness  to  the  urine  observed  in  such  circumstances,  and 
sets  up  early  and  severe  renal  mischief.  Similar  symptoms  may  fol- 
low from  cerebral  disease,  and  occasionally  from  the  general  prostration 
which  follows  from  disease  or  accident  not  directly  connected  with  the 
nervous  system. 

Lastly,  severe  vesical  irritation,  though  unconnected  with  retention, 
may  cause  the  same  results.  The  disorder  was  traced  to  stone  in  the 
bladder  in  fifteen  of  the  sixty-nine  cases  previously  referred  to.  Though 
differently  begun,  a  similar  putrescent  state  of  urine  to  that  of  retention 
is  here  in  the  end  produced,  contamination  by  mucous  discharges  which 
promote  decomposition  being  apparently  the  incipient  evil.  Putrescence 
appears  to  be  always  present.  In  connection  with  the  frequent  origin 
of  the  renal  suppuration  from  vesical  stone,  its  rarity  as  a  consequence  of 
stone  in  the  kidney  is  worth  remarking.  The  difference  probably  lies  in 
the  less  putrefactive  tendency  of  the  discharges  from  the  pelvic  mem- 
brane or  the  less  ready  intrusion  of  septic  agents. 

It  is  frequently  to  be  observed  that  the  conditions  of  bladder  and  of 
urine  apparently  sufficient  to  produce  the  disease  will  exist  for  years 
without  doing  so,  but  that  at  once  upon  some  surgical  procedure,  of 
which  the  use  of  a  catheter  is  probably  the  essential  part,  it  will  start 
into  activity  as  if  the  ready  train  were  thus  lighted.  The  term  "  sur- 
gical kidney,"  so  generally  used  in  reference  to  the  disease,  bears  witness 
to  its  association  with  the  use  of  instruments. 

Linking  the  secondary  renal  mischief  with  ammoniacal  or  putrid 
urine,  and  having  regard  to  recent  researches,  which  have  connected  the 
lower  kinds  of  organic  life  with  pyaemia,'  it  is  worth  noting  that  the  con- 
dition of  urine  which  causes  the  disease  now  in  question  is  one  in  which 
vibriones  and  bacteria  abound;  but  considering  the  different  circumstances 
in  which  such  organisms  appear,  it  would  be  unsafe  to  draw  more  than 
a  provisional  inference  as  to  the  nature  of  the  virus  beyond  the  broad 
fact  that  it  is  associated  with,  and  apparently  dependent  upon,  decompo- 
sition of  urine. 

The  frequency  of  the  disease  after  the  introduction  of  instruments 
may  lead  to  a  surmise  which  must  have  practical  influence,  that  the  es- 
sential virus  is  capable  of  being  conveyed  into  the  bladder  by  their 
means. 

Since  this  conjecture  as  to  the  origin,  or  at  least  an  origin,  of  the  sur- 
gical kidney  was  made  public,  Dr.  Ferrier  has  published  some  experi- 
ments which  corroborate  it.     He  found,  as  indeed  had  before  been  ob- 

'  Dr.  Sanderson,  Pathological  Transactions,  vol.  xxiii.,  p.  303. 


14  ABSCESS    OF    THE    KIDNEY. 

sei'ved,  that  urine,  if  preserved  from  external  contamination,  might  be 
kept  witliout  putrefaction  for  an  indefinite  time,  but  that  the  simple 
contact  of  a  snrface  not  freed  from  germs'  was  enough  to  initiate  the 
putrefactive  process.  In  this  view  the  ammoniacal  state  itself  is  due  to  con- 
tamination from  without.  Whether  this  be  so,  or  whether  urine  may  be- 
come ammoniacal  by  causes  acting  only  from  within,  as  appears  not  im- 
probable, it  is  none  the  less  likely  that  the  especial  virus,  of  which 
tiie  ammoniacal  urine  may  be  only  the  vehicle,  may  be  introduced  by 
such  means.  The  practical  suggestion  as  to  the  invariable  carbolization 
of  catheters  and  bougies  is  too  obvious  to  need  insistance. 

In  connection  with  the  pathology  of  the  disease  I  may  briefly  sketch 
the  symptoms,  drawing  chiefly  from  the  cases  to  which  I  have  already 
alluded.  The  disorder,  particularly  when  the  abscesses,  as  is  too  often 
the  case,  are  widely  disseminated,  runs  a  rapid  and  fatal  course.  The 
patient  generally  dies  within  three  weeks  of  the  first  symptom,  sometimes 
within  a  few  days.  In  fourteen  cases  in  which  the  dates  and  symptoms 
were  carefully  recorded  in  the  hospital  books,  the  duration  of  the  com- 
plaint varied  from  two  to  eighteen  days.  As  an  example  of  its  rapid 
course  I  may  refer  to  an  old  woman  who  was  brought  in  with  a  simple 
fracture  of  the  tiiigh.  Two  days  after  the  accident  she  became  unable 
to  pass  water.  A  catheter  was  used,  and  the  urine  found  to  be  natural. 
It  then  (piickly  became  oflfensive  and  loaded  with  mucus,  and  death  oc- 
curred within  a  week  of  the  injury,  three  days  after  the  urine  changed 
its  character.  Small  purulent  deposits  were  scattered  through  both  kid- 
neys. 

The  course  of  the  disease  resembles  that  of  pyaemia,  differing  from  it 
in  the  usual  exemption  of  other  organs  from  the  suppurative  process. 
The  symptoms  are  general  rather  than  local;  they  point  to  contaminated 
blood  rather  than  to  disturbance  of  glandular  function.  Pain  in  the 
loins,  however,  sometmies  occurs;  and  often  the  urine  is  much  dimin- 
ished, or  even  for  a  time  nearly  suppressed.  Shivering  happens  early 
and  is  apt  to  be  often  repeated,  and  is  sometimes  as  strongly  declared  as 
in  the  case  of  ague.  Febrile  symptoms  rapidly  follow,  Avith  typhoid  pros- 
tration. The  pulse  becomes  rapid  and  feeble,  the  tongue  dry  and  brown, 
the  appetite  absent.  Vomiting  is  a  frequent  and  often  an  urgent  symp- 
tom. Not  seldom  hiccough  occurs,  and  sometimes  diarrhoea,  or  profuse 
sweating.  The  countenance  becomes  anxious  and  haggard,  the  complex- 
ion cadaverous  or  yellow,  and  possibly  with  low  delirium,  the  patient  sinks 
into  utter  prostration,  unconsciousness,  and  death. 

Erysipelas  is  an  occasional  complication,  as  also  is  a  condition  of  pul- 
monary congestion  or  oedema  short  of  that  which  results  in  pyaemic  de- 
posits. 

Dropsy  is  uniformly  absent,  as  in  the  case  of  pyaemia. 

The  disease  is  not  always  fatal.  In  examining  the  bodies  of  persons 
who  have  long  suffered  from  disease  of  the  urinary  organs  it  occasionally 
happens  that  there  are  found  upon  the  kidney  obvious  scars,  often  much 
pigmented,  in  place  and  dimension  such  that  they  may  fairly  be  attrib- 
uted to  ancient  abscesses.  Dr.  Wilks  tells  me  that  he  has  made  the  same 
observation,  and  a  case  of  the  sort  Avas  related  by  Dr.  Moxon  in  the 
twenty-third  volume  of  the  "Pathological  Transactions." 

As  complicating  the  less  rapid  forms  of  the  disorder  must  be  men- 

'  "Septicaemia  and  the  Catheter,"  by  Dr.  Ferrier,  British  Medical  Journal, 
April,  1873. 


ABSCESS    OF    THE    KIDNEY.  15 

tioned  perinepliritic  abscess  from  perforation  of  the  capsule  of  the  kidney 
and  discharge  into  tlie  areohir  tissue. 

In  a  body  recently  examined  at  St.  George's  Hospital,  a  pint  of  pus 
lay  outside  the  suppurating  kidney;  and  preparations  in  the  museum  of 
St.  Mary's  Hospital  illustrate  a  case  in  which  a  vast  collection  of  pus 
reaching  from  the  diaphragm  to  the  groin,  pushing  forward  the  bowels 
and  infiltrating  the  lumbar  muscles,  had  the  same  origin. 

The  treatment  of  the  established  disease  may  be  briefly  described  as 
that  of  pyasmia,  upon  which  it  is  not  needful  to  dwell.  When  the  sup- 
puration has  taken  a  general  hold  of  the  renal  structure,  there  is  probably 
litcle  chance  of  recovery,  though  this  may  follow  the  slighter  or  more 
limited  forms.  The  symptoms  are  mainly  those  of  septicemia,  and  our 
efforts  called  for  to  obviate  death  by  the  attendant  febrile  prostration. 

Quinine  and  alcohol  are  largely  needed,  as  well  as  special  reme- 
dies to  relieve  special  symptoms.  The  vomiting  so  often  present  may  be 
controlled  by  ice  and  creasote,  while  active  purgatives  are  often  called  for 
by  obstinate  constijnition,  and  it  appears  that,  especially  when  the  urine 
is  much  reduced  in  quantity,  the  general  state  of  the  patient  improves 
under  their  operation. 

It  is  sufficiently  clear  with  regard  to  this  disorder  that  our  efforts 
must  be  directed  rather  to  prevention  than  cure;  and  our  knowledge 
of  the  conditions  under  which  it  arises  is  encouraging  in  this  respect. 

The  frequent  appearance  of  the  disease  after  the  use  of  instruments 
makes  it  imperative  never  to  do  so  without  antiseptic  precautions.  The 
association  of  the  disease  with  vesical  inflammation,  and  the  admixture 
of  its  products  with  the  urine,  must  furnish  a  warning  to  both  surgeon 
and  physician,  which  the  latter  may  take  as  an  indication,  in  cases  of 
paralysis  and  prostration,  to  insure  the  regular  and  complete  emptying 
of  the  bladder.  It  is  necessary  to  have  regard  to  the  conclusion  that  the 
disease  is  produced  not  simply  by  cystitis,  but  by  septic  changes  conse- 
quent upon  it,  which  are  associated,  as  it  seems  invariably,  with  an  am- 
moniacal  state  of  urine.  If,  therefore,  this  can  be  prevented,  so  may  be 
the  disease. 

Next  to  the  proper  evacuating  of  the  bladder,  the  greatest  service  in 
the  prevention  of  ammoniacal  decomposition  may  be  rendered  by  acid 
injections  into  it,  of  which  I  have  found  one  containing  nitric  acid  and 
quinine — 15  drops  of  dilute  nitric  acid,  10  grains  of  quinine,  and  10 
ounces  of  water — to  give  the  best  results.  The  bladder  may  be  washed 
out  daily  with  this  or  less  often.  Towards  the  same  end  acids  may  be 
given  by  the  mouth.  The  mineral  acids  are  more  efficacious  than  ben- 
zoic or  any  of  the  ordinary  vegetable  acids,  and  of  the  mineral  acids  I 
have  got  more  decided  results  from  sulphuric  than  from  the  others.  But 
perhaps  nitric  or  nitro-hydrochloric  are  not  greatly  less  effective  in  acid- 
ification, and  may  be  preferable  in  other  respects. 


CHAPTER    11. 
PYELITIS. 

Pyelitis  is  inflammation  of  the  membrane  of  the  pelvis  of  the  kid- 
ney; it  should  not  be  confused,  as  it  often  is,  with  the  disseminated  sup- 
puration of  the  renal  substance  which  may  be  associated  with  it  or  may 
occur  independently.  Pyelitis  is  chiefly  known  as  a  consequence  of  other 
diseases  and  tlie  immediate  cause  of  many  of  their  symptoms.  It  is  con- 
sidered in  connection  with  stone  and  tubercle,  and  referred  to,  perhaps 
sufiicicntly,  as  the  result  of  malignant  gro\vths,  parasites,  and  poisons  of 
the  type  of  cantharides. 

As  [)roduced  by  retention  of  urine  and  the  cystitis  associated  with  it, 
pyelitis  lias  a  large  importance,  already  accorded  to  it,  as  a  frequent,  but 
not  necessary,  intermediary  between  those  conditions  and  the  dissemi- 
nated renal  suppuration  which  they  give  rise  to.  It  is  further  taken  into 
question  as  the  common  first  stage  of  perinephritic  abscess,  and  is  re- 
garded as  originating  in  so  many  different  ways,  and  producing  so  large 
a  variety  of  results,  that  little  can  be  said  separately  concerning  it  which 
would  not  involve  useless  iteration. 

The  pelvis  of  the  kidney  is  not  quick  to  inflame,  though  under  such 
irritants  as  have  been  mentioned  it  may  do  so  somewhat  intensely,  and 
give  issue  to  discharges  so  i^rofuse  and  persistent  as  to  cause  death  by 
exhaustion,  with  the  intervention  either  of  hectic  or  of  lardaceous  dis- 
ease. 

Under  recent  irritation  the  pelvis  of  the  kidney  may  become  highly 
injected,  spotted  with  ecchymoses,  and  coated  with  soft,  false  membrane, 
which  may  have  almost  diphtheritic  separability.  I  have  seen  a  very  dis- 
tinct false  membrane  in  this  situation  as  the  result  of  tinctura  lyttae 
medicinally  given.  The  woodcut  at  p.  81  shows  a  well-marked  sepa- 
rable membrane  formed  upon  the  pelvis  as  the  result  of  tubercular  dis- 
ease; the  membrane  is  seen  to  occupy  the  infundibulum,  and  had  par- 
tially obstructed  the  ureter,  as  the  consequent  dilatation  shows.  This 
result,  however,  of  pelvic  inflammation  is  not  one  of  the  most  common. 
As  the  condition  becomes  chronic,  it  is  usually  marked  by  tiie  white 
opacity  which  is  so  often  associated  with  the  production  of  pus,  varied,  if 
the  disease  be  tubercular,  with  much  roughening,  ulceration,  and  thick- 
ening of  the  pelvis;  it  is  not  necessarily  accompanied  with  dilatation, 
though  the  two  conditions  occur  togetiier  far  more  often  than  either 
separately,  owing  to  the  frequency  witli  which  causes  of  pyelitis  are 
causes  also  of  obstruction  to  the  pelvic  exit.  The  forms  and  results  of 
pelvic  dilatation  have  been  further  referred  to  in  connection  with  stone 
and  perinephritic  abscess. 

Occasionally  the  suppurating  cavity  will  become  closed,  cease  to 
stretch,  and  the  secretion  stop  apparently  because  there  is  no  room  for 
more;  that  which  there  is  becoming  reduced  by  time  and  absorption  to 


PYELITIS. 


17 


little  more  than  its  mineral  residuum.  The  kidney  may  be  converted  by 
th^s  process  into  a  partitioned  cyst,  of  wliich  the  walls  consist  of  little 
more  than  fibrous  tissue,  and  remain  as  harmless  as  useless.  An  example 
of  this  result,  from  the  museum  of  St.  Bartholomew's  Hospital,  is  repre- 
sented in  the  woodcut.  Of  the  kidney  little  remains  but  a  shell  of  fibrous 
tissue,  which  contains  a  substance  like  mortar,  consisting  chiefly  of  phos- 
phate of  lime,  with  a  small  admixture  of  carbonate  of  lime  and  animal 
matter.  It  was  found  in  the  body  of  a  woman  who  died  at  the  age  of 
sixty-two,  having  for  twelve  3'ears  before  had  no  sign  of  renal  disease. 

The  septa  of  such  cysts  have  become  calcified,  and  true  bone  has 
been  found  in  them,  as  in  an  instance  recorded  by  Dr.  Roberts. 

Little  remains  to  be  said  except  to  indicate  one  or  two  causes  of  pye- 
litis which  do  not  find  place  elsewhere,  and  to  refer  to  some  results  of  it 


Kidney  converted  into  bag  of  earthy  matter,  as  the  result  of  pyelitis. 

which  may  be  attributed  rather  to  itself  than  to  the  diseases  with  which 
it  may  be  associated. 

The  lesser  degrees  of  pyelitis,  more  often  evident  after  death  than 
during  life,  may  ensue  upon  almost  any  change  in  the  urine,  more  espe- 
cially if  it  be  alkaline.  Advanced  albuminuria  and  diabetes  may  be  thus 
accompanied,  though  usually  to  an  unimportant  extent.  With  regard  to 
chyluria,  I  have  recently  seen  an  instance  in  which  this  disease,  contracted 
in  India  by  a  boy  at  the  age  of  four,  was  found  to  have  been  succeeded  at 
the  age  of  seven  by  a  profuse  and  constant  discharge  of  puS;  presumably 
from  the  pelvis;  the  urine  retained  its  acidity,  and  there  was  a  total  ab- 
sence of  bladder  symptoms.  This  discharge  continued  under  observation 
for  a  year  and  a  half;  I  then  lost  sight  of  the  child  for  three  years,  at  the 
2 


18  PYELITIS. 

end  of  which  time  the  urine  was  natural  and  the  child  well.  "Whether  ia 
connection  with  urinary  change  or  the  extension  of  vesical  inflammation, 
pyelitis  often  takes  place  in  connection  with  stricture,  stone  in  the  blad- 
der, and  paralysis,  together  with  the  disseminated  suppuration  which  lias 
been  considered  elsewhere.  And  often  when  this  graver  complication 
has  not  been  induced,  pyelitis  alone,  or  accompanied  only  with  inflamma- 
tion of  the  bladder,  may  ensue  from  the  same  causes,  any,  to  wit,  which 
involve  retention  and  decomposition  of  urine — diseases  and  injuries  of 
the  nervous  system,  typhus,  and  all  other  states  attended  with  inaction 
of  the  bladder,  whether  from  paralysis  or  prostration. 

When  thus  uncomplicated,  this  disease  is  transient,  if  the  cause  is  so, 
and  has  little  clinical  importance. 

It  may  be  observed  in  passing  that  pyelitis,  unattended  with  dissem- 
inated suppuration,  does  not  give  rise  to  the  signs  of  septic  absorption, 
resembling  those  of  pyaemia,  which  belong  to  the  latter  disease,  though 
it  may  produce  results,  as  will  presently  be  seen,  allied,  though  dissim- 
ilar. The  failure  to  mark  the  distinction  between  the  two  conditions  has 
caused  much  confusion. 

Apart  from  urinary  changes,  gout,  gonorrhoea,  and  apparently  preg- 
nancy, have  definite  place  as  causes  of  pyelitis.  With  gout  and  gonorrhoea 
the  inflammation  creeps  from  the  bladder  up  one  or  both  ureters — if 
both,  often  successively  rather  than  simultaneously — and  so  reaches  the 
cavity  of  the  kidney.  Gouty  inflammation  of  the  bladder,  with  its  dis- 
tressing frequency  and  sometimes  intolerable  pain,  the  urine  first  highly 
acid  and  then  purulent,  is  a  phase  of  tiie  constitutional  disease  which  has 
received  little  notice,  though  sufficiently  striking.  It  would  seem  that 
the  pelvis  of  the  kidney  may  be  similarly  affected  in  sequence  to  it.  I 
saw,  with  Dr.  Baber,  a  lady  between  sixty  and  seventy  years  of  age,  the 
member  of  a  gouty  family,  though  never  herself  the  subject  of  gout  in 
any  ordinary  form.  After  exposure  to  the  severe  cold  of  January,  1881, 
together  with  the  mental  shock  attendant  upon  the  partial  destruction 
of  her  house  by  the  explosion  of  a  boiler,  she  had  severe  cystitis,  constant 
vesical  pain,  incessant  micturition,  and  the  passing  of  highly  acid  scanty 
urine,  loaded  with  lithates  and  containing  pus.  After  about  a  fortnight, 
the  pain  and  tenderness  passed  up  the  course  of  the  left  ureter,  and  be- 
came fixed  in  the  position  of  the  left  kidney ;  a  week  or  two  later  pre- 
cisely the  same  process  took  place  with  regard  to  the  right  ureter  and 
kidney.  It  was  next  found  that  the  pain  in  the  right  side  was  enhanced 
when  the  patient  turned  upon  her  face,  a  tumor  at  the  same  time  falling 
forwards  from  the  loin,  possibly  a  kidney  dilated  as  the  result  of  j^yelitis. 
Siie  had  never  passed  stone  or  gravel. 

I  have  more  than  once  recognized  a  similar  ascendiYig  inflammation 
as  the  result  of  gonorrhoea,  cystitis  being  succeeded  by  pain  along  the 
ureters,  and  that  by  pain  of  a  more  lasting  character,  together  with  deep 
tenderness  in  the  position  of  both  kidneys,  the  urine  containing  pus  but 
givrjig  no  evidence  of  disease  of  the  renal  substance. 

A  form  of  renal  colic,  preceded  by  chill  and  fever,  and  regarded  as 
pyelitis,  has  boon  described  as  occurring  in  the  puerperal  state.  The  urine 
is  said  to  be  albuminous,  and  to  contain  such  epithelium  as  the  pelvis 
affords.  I  have  known  severe  renal  colic  at  the  close  of  pregnancy  to  be 
succeeded  and  explained  by  the  abundant  escape  of  gravel.  The  pyelitis 
of  pregnancy,  if  there  be  any,  apart  from  such  irritation  has  nothing  in 
common  with  the  suppurative  extension  known  to  occur  after  delivery, 
and  produce  perinephritic  abscess. 


PYELITIS.  19 

The  general  symptoms  of  pyelitis,  independently  of  those  of  the  dis- 
ease, whatever  it  be,  which  has  given  rise  to  it,  may  be  briefly  indicated. 

Pain  may  travel  up  the  ureters,  as  in  the  cases  referred  to,  and  be- 
come fixed  in  the  lumbar  regions,  as  dull  or  weighty  ;  but  in  many  in- 
stances and  for  long  periods  there  is  no  ])ain  at  all,  or  only  what  must  be 
attributed  to  the  disease  in  which  tlie  pyelitis  has  arisen.  If  the  exit  is 
free,  there  will  be  no  such  tumor  as  can  be  appreciated  from  Avithout, 
except,  as  sometimes  in  the  case  of  tubercle,  the  original  disease  be  at- 
tended with  this  degree  of  tumefaction.  If  the  ureter  be  closed,  the 
swelling  may  be  felt  from  before  and  behind,  more  often  as  a  small  than 
as  a  large  renal  tumor.  Such  are  detailed  too  fully  elsewhere  to  need 
description  here.  There  may  be  at  the  beginning  a  discharge  of  mucus 
or  of  blood,  and  the  latter  may  be  repeated  at  intervals  throughout  the 
course  of  the  disease,  particularly  if  associated  with  stone,  and  sometimes 
if  with  tubercle.  More  characteristic  is  the  persistent,  or  persistently  re- 
curring, discharge  of  pus  with  the  urine,  together  with  evidence  that  it 
is  derived  from  the  pelvis,  or,  what  may  be  equivalent,  that  it  is  not  de- 
rived from  the  bladder.  If  the  exit  is  unimpeded  the  pus  is  "  laudable  " 
and  inoffensive  ;  on  standing,  it  separates  somewhat  abruptly  from  the 
urine,  which  retains  its  acidity.  It  has  been  stated  so  frequently  that  a 
discharge  from  the  pelvis  of  the  kidney  can  be  distinguished  by  the  epi- 
thelial cells  Avhich  are  shed  with  it  that  I  almost  hesitate  to  assert,  what 
I  have  taken  some  trouble  to  ascertain,  that  there  are  no  characters  by 
which  detached  cells  of  pelvic  e])ithelium  can  be  positively  recognized, 
however  practicable  it  might  be  to  distinguish  the  pelvic  membrane  could 
it  be  seen  in  mass. 

Roberts  describes  the  epithelium  shed  as  the  result  of  pyelitis  as  be- 
ing "very  irregular,  spindle-shaped,  tailed,  three-cornered,  elongated, 
rudely  circular,  etc.,"  and  as  thus  affording  certain  evidence  of  its  origin. 
It  will  be  seen,  however,  that  these  varieties  of  form,  even  to  the  "etc.," 
are  equally  cliaracteristic  of  vesical  disease.  Ebstein  in  '"' Ziemssen's 
Cyclopedia,"  describes  the  pelvic  epithelium  as  characteristic  in  virtue 
of  its  shapes — "  flattened,  laminated,  and  caudate  " — terms  equally  ap- 
plicable, as  the  annexed  woodcut  will  show,  to  epithelium  derived  from 
other  parts  of  the  urinary  tract.' 

'  In  view  of  the  localization  of  disease  by  the  urinaiy  deposit,  it  is  necessary 
to  ascertain  how  far  tiie  epithelium  from  each  part  of  the  tract  can  be  distin- 
guished. The  accompanying  woodcut  shows  the  varieties  of  cells  which  were  ob- 
tained fi-om  each  part  of  the  urinary  course  in  a  succession  of  individuals  not  tlie 
subjects  of  urinaiy  disease.  The  results  are  not  valueless,  but  perliaps  disap- 
pointing; they  amount  to  this:  The  solid  polygonal  figures  of  the  renal  epithe- 
lium, of  small  andunifoi'm  size,  can  be  easily  recognized;  diseases  in  which  they 
are  abundantly  shed  are  commonly  evident  enough  without  them.  Between  the 
pelvis  and  the  ui-eter  no  distinction  can  be  made  with  certainty;  both  abound  with 
club-shaped  and  tailed  cells,  and  yield  also  others  variously  squared,  rounded, 
and  flattened,  but  none  which  are  distinctive  of  either  situation.  In  the  bladder 
are  abundant  club-shaped  fusiform  aiid  rhomboidal  cells,  not  to  be  distinguished 
from  those  which  belong  to  the  pelvis  and  ureter,  and  others  which  are  more 
significant,  though  perhaps  none  which  aie  absolutely  limited  to  this  organ.  The 
most  characteristic  cells  are  large  and  numerously  scooped  for  adaptation  with 
smaller  cells  below;  these  are  not  often  to  be  recognized  in  morbid  discharges, 
but  must  be  accepted  as  valuable  indications  when  they  are.  Besides  these  are 
other  cells,  the  like  of  which  are  to  be  found  in  other  situations,  but  w^hen  large, 
well  marked,  and  numerous,  may  be  generally  reckoned  as  vesical.  These  ar<» 
large,  rolling  globes  or  spheroids,  with  a  well-marked  outline  and  usually  a  single 
nucleus.  The  urethra  may  yield  cells  of  many  sorts,  some  globular  and  coherent, 
probably  of  glandular  origin,  others  flattened,  spindle-shaped,  and  of  solid  poly- 


20 


PYELITIS. 


'0 


© 


@3 


Cones  of 
kidnej-. 


Pelvis. 


Ureter. 


Bladder. 


®®_0 


Urethra. 


o  ;p. 


Vagina. 


Varieties  of  Epithelium  from  Urinary  Tract  in  Health,    x  220. 


PYELITIS.  "21 

Often.,  as  the  result  of  pyelitis,  the  urine  may  be  foetid  from  the 
presence  of  putrescent  i)urulent  matter  and  still  be  acid.  The  alkalinity 
of  the  discharge  from  the  diseased  kidney  is  overpowered  by  the  acidity 
of  the  normal  urine  from  the  healthy  one.  Had  the  decomposition 
taken  place  in  the  bladder,  it  would  have  affected  all  the  urine  alike  and 
made  it  ammoniacal throughout  had  it  proceeded  to  any  extent.  Another 
indication  of  pyelitis  which  admits  of  a  similar  explanation  is  the  pres- 
ence in  acid  urine  of  triple -phosphate  crystals,  Avhich  in  these  circum- 
stances often  show  signs  of  superficial  solution,  from  their  exposure  to 
acid  urine  after  their  formation  necessarily  in  alkaline.  The  urine  of 
pyelitis  is  often  peculiarly  disgusting,  redolent  rather  of  sulphuretted 
hydrogen  than  ammonia,  or  distinctly  of  both.  The  urine  of  bladder 
disease  is  more  simply  ammoniacal. 

The  discharge  tlius  foetid  is  apt  to  intermit  completely  or  partially, 
being  retained  and  decomposing  in  the  cavity.  When  it  appears  it  may 
present  to  the  microscope  a  mere  shapeless  debris,  from  which  all  cor- 
puscular shape  lias  disappeared.  Tlie  collection  and  decomposition  of 
the  urine  in  the  pelvis  is  sometimes  attended  with  signs  of  blood-poison- 
ing, different,  Jiowever,  from  .those  which  proceed  from  disseminated 
suppuration.  With  the  latter  the  symptoms  have  a  ]na3mic  type,  "witli 
fever  at  best  remittent,  and  often  with  a  jaundiced  skin.  With  pyelitis 
there  are  fever  and  eruption,  but,  as  far  as  I  have  seen,  no  jaundiced  or 
py^emic  tint.  The  fever  and  eruption  are  both  transient,  the  fever  often 
without  eruption,  but  the  eruption  seldom  without  some  degree  of  fever. 
Febrile  attacks  with  a  temperature  up  perhaps  to  101°  may  come  on, 
last  for  a  longer  or  shorter  time,  and  then  pass  away  completely.  These 
are  usually  without  organic  change,  but  sometimes  associated  with  a 
degree  of  pneumonia.  The  eruption  which  presents  itself,  though  by  no 
means  regularly,  as  the  result  of  pyelitis  is  usually  to  be  classed  as  ery- 
thema, at  least  it  consists  of  little  more  than  injection  of  the  skin,  with- 
out the  separation  of  serum  or  pus.  This  may  occur  in  vivid  spots  or 
blotches,  the  latter  often  confluent.  They  occur  mostly  on  the  face,  but 
occasionally  on  the  trunk.  The  eruption  may  somewhat  resemble  that 
of  measles,  or  more  often  what  is  called  German  measles.  It  sometimes 
presents  itself  as  herpes,  the  blotches  being  succeeded  by  the  character- 
istic vesicles. 

The  course  and  duration  of  pyelitis  vary  as  widely  as  its  causes,  and 
cannot  be  considered  but  in  connection  with  them.  When  from  stone, 
the  disorder  is  indefinite  in  length,  and  may  intermit  completely  for  con- 
siderable spaces.  When  from  tubercle,  it  is  more  brief;  the  discharge 
is  constantl}''  present  while  it  lasts  ;  if  it  ceases  the  cessation  is  linaL 
Among  the  results  of  the  disease  the  lardaceous  change  takes  a  ])romiiient 
position,  though  death  may  be  brought  about  independently  of  it  by  fever 
and  hectic,  or  nuiy  ensue  upon  rupture  into  the  i)eritoneum,  into  the 
bowel,  or  externally  in  modes  which  are  considered  in  relation  to  stone, 
tubercle,  and  perinephritic  abscess.  Urtemia  is  not  a  consequence  of 
pyelitis,  though  it  may  ensue  from  many  of  the  disorders,  obstructive  or 
destructive,  with  which  pyelitis  may  be  associated. 

To  show  the  chronicity  or  tolerance  of  the  disease,  I  may  refer  to  a 

gonal  shapes.  When  many  strongly  marked  squamous  cells  are  to  be  seen,  par- 
ticularly if  they  are  imbricated,  they  may  be  attributed  to  the  vagina.  It  is  to  be 
noted  that  some  of  tlie  vaginal  cells  in  the  woodcut  were  obtained  from  the 
bodies  of  children,  and  are  smaller  and  less  strongly  marked  than  at  more  ad- 
vanced ages. 


22  .  rvKLiTis. 

young  hidy  now  (1882)  fifteen  years  of  age,  and  in  fair  general  health, 
who  has  been  under  my  care  with  it  for  eleven  years.  The  cause  is  prob- 
ably stone.  The  urine  is  never  quite  free  from  discliarge,  the  quantity 
and  fcBtor  of  wliich  are  exasperated  at  irregular  intervals.  There  have 
been  occasional  attacks  of  fever  and  eruption  such  as  have  been  described, 
and  the  cliaracter  of  the  dislodged  epithelium  was  such  at  least  as  to  ex- 
clude a  vesical  origin.  That  it  was  not  from  the  vagina  was  not  equally 
certain.  Occasionally,  particularly  after  increased  exercise,  the  urine 
disi)laced  translucent  flakes  like  bran  or  very  minute  fragments  of  silver 
paper.  These  consisted  of  masses  of  flat  epithelial  scales,  placed  with 
some  regularity,  and  crossed  here  and  there  with  lines  of  fibrous  tissue. 
This  patient  apparently  owed  her  endurance  of  the  disease  to  quinine, 
mineral  acid,  and  frequent  change  from  London  to  the  country  or  sea- 
side. 

The  treatment  of  pyelitis  resolves  itself  into  the  treatment  of  stone, 
tubei'cle,  and  gout,  together  with  the  correction  of  alkalinity  and  foetor 
in  the  urine,  and  the  compensation  of  exhausting  discharge.  No  pro- 
cess of  counter-irritation  has  found  support  by  my  experience  ;  indeed 
the  disorder  is,  as  a  rule,  too  deep  to  be  benefited  by  any  local  treatment. 
"Where  the  urine  has  been  persistently  or  occasionally  alkaline,  or  even 
where  it  has  been  only  reduced  in  acidity,  I  have  found  the  greatest  use 
in  nitro-muriatic  acid,  together  with  quinine  and  other  tonics.  Where 
it  is  fojtid,  and  a  source  of  mischief  by  its  retention  and  absorption,  I 
have  thought  decided  benefit  to  ensue  from  the  administration  of  crea- 
sote.  It  is  more  easy  to  recognize  the  effect  of  this  antiseptic  upon  foetid 
discharges  of  many  kinds  than  to  explain  the  transmission  of  it  as  such 
to  the  place  in  question.  When  the  discharge  is  chronic  and  exhausting, 
much  may  be  done  by  liberal  diet,  quinine,  iron,  and  change  of  air,  es- 
pecially to  such  seaside  places  as  are  reputed  ''bracing."  Where  pyelitis 
is  conjoined  with  obstruction  of  the  outlet  and  has  led  to  so  much  ac- 
cumulation of  pus  as  to  cause  bulging  in  the  loin,  the  question  of  punc- 
ture or  incision  from  that  surface  may  be  entertained  ;  but  I  think  it  is 
generally  safest  to  wait  until  the  matter  has  worked  through  its  renal  in- 
vestment and  presented  in  the  back,  and  even  then  until  it  is  nearly 
s>ubcutaneous  rather  than  to  seek  for  it  deeply.  The  consideration  of 
this  question  belongs  to  the  subject  of  perinephritic  abscess. 


CHAPTER  III. 

SUPPURATIVE   PERINEPHRITIS. 

If  the  terms  perinephritis  and  perinephritic  abscess  were  confined,  as 
in  strictness  they  might  be,  to  abscess  or  inflammation  beginning  in  and 
essentially  belonging  to  the  renal  circumference,  there  would  be  little  to 
add  to  what  is  to  be  found  under  several  headings  of  renal  abscess,  stone, 
and  tubercle.  But  though  in  the  large  majority  of  cases  suppuration  on 
the  outside  of  the  kidney  is  directly  produced  by  suppuration  within  it, 
yet  there  are  enough  cases  in  which  this  is  not  so  to  make  it  necessary  to 
refer  to  perinephritis  independently  as  well  as  in  its  relation  to  renal  dis- 
ease. 

Irrespectively  of  its  origin,  pus,  issuing  from  the  kidney  or  formed  in 
contact  with  its  surface,  commonly  remains  behind  the  peritoneum,  bur- 
rowing among  the  deep  muscles  and  fascia  of  the  lumbar,  pelvic,  and 
■crural  regions.  An  abscess  of  extra-renal  origin  more  often  begins  be- 
hind the  kidney  than  in  front  of  it,  and  thus  has  this  organ  between 
itself  and  the  serous  cavity  :  the  same  will  of  course  happen  should  a 
renal  abscess  open  posteriorly.  If  it  break  anteriorly  it  may  penetrate 
the  peritoneum  directly  and  set  upon  fatal  peritonitis  ;  but  even  when 
thus  escaping  from  the  front  this  result  is  not  inevitable,  for  the  matter 
may  either  lift  up  the  peritoneum  and  spread  laterally  behind  it,  or  in 
perforating  it  may  become  so  circumscribed  by  adhesions  that  the  abscess 
is  as  good  as  post-peritoneal,  though  not  actually  so. 

The  capsule  of  the  kidney  itself  often  displays  a  remarkable  power  of 
confining  matter  within  it.  There  is  a  preparation  at  the  College  of  Sur- 
'geons  in  which  at  least  half  a  pint  of  matter  had  collected  between  the 
capsule  and  the  gland,  which  retain  but  few  points  of  contact. 

The  fat  and  cellular  tissue  around  the  kidney  are  in  close  apposition 
with  the  muscles  of  the  back,  and  not  separated  from  the  origin  of  the 
psoas  muscle,  the  structures  behind  the  iliac  fascia,  the  sacro-sciatic  fo- 
ramen, or  the  course  of  the  great  vesselsfrom  the  trunk  to  the  thigh. 
Pus  will  easily  traverse  areolar  and  muscular  tissues,  but  penetrates  fasciie 
and  membranes  with  difficulty.  It  thus  readily  crosses  the  lumbar  re- 
gion, or,  taking  advantage  of  natural  channels,  passes  down  the  psoas 
muscle  to  the  inguinal  region,  or  with  the  blood-vessels  to  the  front  of 
the  thigh,  or  through  the  sacro-sciatic  foramen,  to  appear  upon  the  glu- 
teal surface. 

The  passage  of  such  matter  down  the  psoas  muscle  is  of  interest  in 
relation  to  diagnosis.  It  is  usually  accompanied  with  flexion  of  the 
tiiigh,  a  symptom  which  may  therefore  be  produced  by  disease  of  renal 
origin  as  well  as  by  disease  of  the  spine.     I  published  a  case  many  years 


24:  surrL'KATivE  perinephritis. 

ago  in  the  "  Pathological  Transactions,'"'  in  which  a  psoas  al)scess  had 
taken  its  origin  in  tubercnlar  disease  of  the  kidney,  and  have  since  known 
the  same  resnlt  to  ensue  from  suppuration  arising  in  stone. ^ 

Another  mode  of  exit  which  is  comparatively  frequent  is  by  the  bron- 
chial tubes.  Matter  of  renal  as  of  hepatic  origin  often  passes  upwards. 
It  enters  the  muscular  lamina?  of  the  back  and  readily  si)reads  between 
them,  thus  passing  behind  the  diaphragm  into  the  root  of  one  of  the 
lungs,  commonly  evading  the  pleura  and  penetrating  the  lower  part  of 
the  lung  directly.  By  this  means  localized  i)neunionia  has  been  set  up, 
and  not  infrequently  the  pus  has  found  its  way  into  one  of  the  bronchi 
and  so  been  coughed  up. 

It  has  been  known  also  to  be  discharged  by  ulceration  into  the  vagina, 
into  the  bladder,  and  through  the  prostate  into  the  urethra.^  The  great- 
est; variety  of  exit  is  presented  by  abscesses  of  calculous  origin.  These 
have  been  known,  as  detailed  elsewhere,  to  discharge  themselves  super- 
ficially upon  tiie  loin,  the  gluteal  region,  the  groin,  the  thigh,  to  enter 
the  ]ieritoneal  cavity,  the  ascending  transverse  and  descending  colon,  the 
duodenum,  the  stomach,  and  the  bronchial  tubes. 

The  commonest  issue  is  upon  the  back,  where  a  wide,  brawny, 
doughy,  or  boggy  surface,  possibly  erysipelatous  or  phlegmonous,  pre- 
sents itself  between  the  last  rib  and  the  crest  of  the  ilium.  The  hands 
before  and  behind  the  renal  position  may  distinctly  appreciate  a  fulness 
in  it  which  will  not  move  with  respiration,  as  it  might  were  it  connected 
with  tiie  liver  or  spleen.  It  is  upon  the  loin  that  incisions  are  most  often 
called  for,  and  from  it  that  calculi  more  often  make  their  exit  than  from 
any  other  part  of  the  cutaneous  surface. 

Circumrenal  abscess  in  its  more  ordinary  forms,  as  the  result  of  in- 
trarenal  suppuration,  has  found  sufficient  mention  elsewhere.  By  far 
the  most  frequent  of  these  is  that  in  connection  with  calculus  and  pro- 
duced by  dilatation  of  the  pelvis,  disproportionate  extension  of  one  of 
the  calyces,  and  perforation  by  it  of  the  renal  capsule.  Tubercular  sup- 
puration also  will  sometimes  reach  the  outside  of  the  kidney,  a  suppu- 
rating mass  impinging  upon  and  penetrating  the  capsule  and  possibly 
entering  the  duodenum  or  descending  colon.  Pus  of  this  origin,  how- 
ever, docs  not  as  a  rule  travel  far  or  collect  in  great  abundance.  Ab- 
scesses of  wide  range  have  been  known  to  ensue  from  the  perforation  of 
the  capsule  by  pyajmic  and  "surgical"  renal  abscesses.  Instances  of 
extensive  extra-renal  abscesses  are  related  in  connection  with  both  these 
subjects. 

Wounds  and  contusions  involving  the  kidney  or  its  surroundings  have 
been  followed  by  su[)puration  about  it.  Wounds  from  the  front  neces- 
sarily open  the  peritoneum  and  are  fatal  by  extravasation  of  urine  within. 
But  the  kidney  may  be  pierced  from  behind  by  a  bullet  or  otherwise,  so 
that  the  escape  will  take  place  into  the  posterior  tissues,  and  spread  more 
or  less  round  the  organ,  with  matter  widely  disposed  but  still  behind  the 
serous  membrane.     Such  a  case  is  described  by  Baudeur.'     A  musket-ball 

'  Pathological  Transactions,  vol.  xvi.  1865,  p.  175. 

^  See  Chapter  XIII.  As  touching  the  relationship  between  urinary  and  psoas 
disease,  I  may  mention  that  there  is  a  preparation  at  King's  College  in  which 
there  has  been  a  reversal  of  the  process  here  described.  An  ordinary  psoas  ab- 
scess lias  discharged  itself  into  the  ureter,  the  matter  from  tiiis  source'thus  escap- 
ing by  the  urinary  channels.  So  far  the  symptoms  of  renal  were  produced  by 
psoas  abscess. 

*See  case  quoted  by  Feron,  loc.  cit.  p.  33. 

<  Quoted  by  Parmentier,  L' Union  Medicale,  August,  1863,  p.  408. 


SUPPLKATIVK    rEKIAEl'HKlTlS.  25 

entered  the  left  loin  of  a  soklicr,  nc:ir  the  second  lumbar  vertebra;  re- 
traction of  the  testicle  and  painful  emission  of  urine  followed;  a  collec- 
tion of  matter  then  formed  ajjparently  between  the  kidney  and  the  wall 
of  the  abdomen,  which  at  last  was  reached  by  a  sound  introduced  through 
the  wound,  and  thus  successfully  got  rid  of. 

Bruises  of  the  lumbar  region  may  also  be  followed  by  suppuration 
around  the  kidney/  A  French  peasant  fell  from  a  tree  and  severely 
bruised  the  right  loin;  hoematuria  at  once  followed,  and  then  deep-seated 
jiain,  fever  and  lumbar  swelling,  with  recurrent  rigors;  an  incision  out- 
side the  lumbo-saci'al  mass,  where  fiuctualion  had  become  evident,  gave 
exit  to  a  quantity  of  "^  phlegmonous  "  pus,  and  was  followed  by  recover}'.'^ 
In  another  instance  a  nurse  fell  down-stairs  and  struck  her  right  side 
upon  the  edge  of  a  pail.  The  urine  became  slightly  and  temporarily 
bloody;  slie  had  fever,  delirium,  and  diarrhcea;  swelling  appeared  in  the 
lumbar  region,  levelling  the  costo-iliac  hollow  and  extending  into  the 
right  hypochondrium,  filling  the  interval  between  the  liver  and  the  iliac 
fossa,  and  reaching  to  the  left  across  the  median  line.  An  openingin  the 
loin,  begun  with  caustic  potash  and  completed  by  puncture,  gave  exit  to 
a  profuse  discharge  of  pus,  and- led  to  the  recovery  of  the  patient.  The 
right  leg  had  been  paralyzed  for  four  or  five  days  during  the  height  of 
the  disorder. 

Violent  strains  of  the  back  have  been  followed  by,  and  apparently 
have  produced,  abscess  in  the  renal  vicinity.  Trousseau  mentions  the 
case  of  a  workman  in  the  plaster  quarries  who  felt  acute  pain  in  the  left 
lumbar  region  while  lifting  a  heavy  load.  Tumefaction,  redness,  and 
widely  lancinating  pain  were  succeeded  by  deep  fluctuation  in  the  af- 
fected loin,  incision,  and  the  discharge  of  a  quantity  of  pus,  which  was 
ascertained  by  means  of  a  probe  to  come  from  immediately  behind  the 
left  kidney.  The  patient  recovered.  It  is  probable  that  when  suppura- 
tion thus  follows  a  strain,  there  occurs  either  some  deep  rupture  of  mus- 
cle or  tendon,  or  possibly  the  final  giving  way  of  some  part  of  the  renal 
surface  previously  undermined  by  disease. 

But  there  are  other  causes  and  shapes  of  perinephritis  which  are  more 
obscure,  and  perha})S  some  are  adduced  which  are  problematical.  Tiie 
large  amount  of  cellular  tissue  about  the  kidneys,  and  generally  between 
the  pelvis  and  the  ribs,  presents  this  interval  as  a  favorable  seat  for  dis- 
orders which  are  proper  to  this  tissue,  while  the  proximity  of  the  region 
to  other  organs  and  to  large  vessels  renders  it  liable  to  be  invaded  by  mat- 
ter which  has  taken  its  origin  elsewhere.  An  abscess  beginning  in  con- 
nection with  some  other  organ,  or  in  the  cellular  tissue  itself  as  a  result 
of  pysemia  or  some  febrile  or  other  general  condition  which  invites  sup- 
puration, or  possibly  from  some  local  cause,  whether  hydatids  or  of  some 
sort  to  be  less  readily  discovered,  may,  though  entirely  independent  of 
the  kidney,  either  begin  in  its  immediate  neighborhood  or  so  soon  reach 
it  to  expatiate  in  the  loose  tissue  around  as  to  behave  as  if  it  had  taken 
its  origin  in  this  organ. 

The  apposition  of  the  large  bowel  to  each  kidney  without  the  inter- 
vention of  peritoneum  is  important,  not  only  as  allowing  of  the  passage 
of  matter  from  the  kidney  to  the  bowel,  but  also  permitting  it  to  pass 
in  the  reverse  direction,  from  the  bowel  to  the  kidney.  Abscesses,  es- 
pecially from  stone,  may  escape  into  the  ascending  as  well  as  into  the 

'  Berounbioux,  quoted  by  Trousseau,  loc.  cit.  vol.  v.  p.  338. 
'  Bienfait,  quoted  by  Trousseau,  loc,  cit.  vol.  v.  p.  339. 


26  SUPPURATIVE    PERINEPHRITIS. 

descending  colon,'  tliougli  they  do  not  so  often  do  so;  and  we  have  evi- 
dence that  matter  may  be  directed  from  the  circumference  of  the  ascend- 
ing colon  to  that  of  the  right  kidney,  this  transference  of  the  disease 
being,  as  it  would  seem,  more  frequent  on  the  right  side  than  the  left, 
possibly  because  the  looser  peritoneal  arrangements  of  the  ascending  colon 
give  more  room  for  the  accumulation  of  pus  than  is  to  be  found  on  the 
left  side.  A  man  swallowed  a  pin;  this  caused  perforation  of  the  ascend- 
ing colon,  and  an  extra-peritoiK-al  abscess  in  the  right  lumbar  region, 
which  contained  gas  and  ftecal  matter.-  And  there  is  much  probability 
tliat  the  anatomical  associations  of  the  beginning  of  the  large  bowel 
with  the  right  kidney  may  serve  to  explain  other  cases  of  circumrenal 
suppuration,  of  which  the  origin  is  less  obvious.  A  large  abscess  in  this 
situation  is  described  by  M.  Lemoine^  as  having  its  anterior  wall  formed 
by  the  ctecum  and  tiie  ascending  colon.  No  ulceration  of  the  bowel  was 
found,  but  the  beginning  of  the  disorder  had  been  marked  by  violent 
colic  and  vomiting;  pus  discharged  through  an  incision  made  during  life 
had  been  extremely  foetid;  the  kidney,  which  was  surrounded  by  the  mat- 
ter, was  softened  externally,  but  evidently  not  its  source;  and  it  may  at 
least  be  surmi-sed  that  the  origin  of  the  disorder  was  intestinal. 

A  remarkable  febrile  disorder  was  described  by  Butter  as  the  Ply- 
mouth Dockyard  disease,*  which  must  be  considered  to  have  been  an 
endemic  forni  of  septicaemia,  due  to  some  localized  poison  which  was  not 
traced  to  its  source.  The  symptoms  were  more  nearly  analogous  to  those 
which  sometimes  follow  dissection  wounds  than  to  those  of  any  of  the 
specitic  fevers.  Slight  wounds  or  abrasions  received  in  tlie  dockyard 
were  succeeded  in  a  number  of  instances  by  intense  fever,  erysipelatous 
iiidammations,  effusions  of  serum  and  pus  into  the  cellular  tissue,  local- 
ized gangrene,  intense  injection  or  inflammation  of  the  ileo-crecal  region 
of  the  bowel,  as  discovered  on  posf-morfem  examination,  and  in  two  of 
fifteen  cases  by  suppurative  nephritis,  or  perinephritis.  In  one  of  these 
instances,  "  the  mesentery  and  meso-colon  were  vascular  with  red 
patches,  the  whole  being  amassed  in  sero-purulent  fluid.  Tiie  right  kid- 
ney was  completely  disorganized,  and  changed  into  a  mass  like  thick 
cream  in  color  and  consistence.  The  left  kidney  was  sound."'  In  the 
other  case,  the  lower  part  of  the  ileum  and  caecum  were  inflamed  nearly 
to  gangrene,  while  behind  the  bowels  and  around  the  right  kidney, 
which  itself  was  healthy,  was  found  a  pint  of  pus.  It  may  be  conjec- 
tured that  in  these  cases  the  pus  may  have  travelled  backwards  from  the 
ileo-cteeal  region  of  the  bowel,  by  way  of  the  meso-colon,  and  a  similar 
explanation  may  possibly  apply  to  the  origin  of  perine[)hritic  abscess  in 
typhoid — a  pathological  secpience  which  has  been  noticed  though  not  ex- 
plained.^ 

Pus,  also,  which  has  taken  its  origin  in  disease  of,  or  operations  npon, 
the  rectum,  has  been  known  to  creep  up  the  subiDcritoneal  tissue  and 
reach  the  renal  vicinity." 

'  See  Case  related  by  Parmentier,  L'  Union  Medicale,  September,  1862,  p.  441. 

'  Parmentier.  "  Sur  les  Abscess  perinephretiques,"  Z,'  Union  Medicale,  August, 
1862,  p.  408. 

^  "  Abscess  Perinephrique,"  M.  Letnoine.  L!  Union  Medicale,  June  19th,  1863, 
p.  551. 

■•  Remarks  on  Irritative  Fever,  commonly  called  the  Plymouth  Dockyard  Dis- 
ease, by  Dr.  Butter.     Devonport,  1825. 

''  Trousseau,  Clinical  Lectures  (Sydenham  Eklition),  vol.  v.  p.  343. 

*  K()fni<<,  quoted  by  Ebstein,  Zieinssen's  Cyclopaedia,  vol.  xv.  p.  589. 


SUPPURATIVE    PERINEPHRITIS.  27 

The  consequences  of  labor  are  unequivocally  associated  with  suppura- 
tion in  the  neighborhood  of  the  kidney. 

Iliac  and  otlier  abscesses  are  apt  to  form,  as  is  well  known,  in  these 
circumstances,  as  results  of  venous  absorption,  and  there  is  nothing  to 
prevent  the  extension  of  matter  from  the  iliac  to  the  renal  region.  A 
case  is  described  by  Trousseau,  in  his  admirable  lecture  on  perinephritis, 
in  which  pus  so  produced  invaded  successively  the  right  broad  ligament, 
the  circumrenal  and  the  iliac  regions.  The  abscess  was  first  found  in 
connection  with  the  right  uterine  appendages,  and  acquired  from  thence 
two  outlets,  one  into  the  bladder,  the  other  into  the  vagina.  An  inter- 
val of  improvement  was  followed  by  rigors,  fever,  pain  in  the  right  side, 
and  swelling  which  filled  up  the  right  costo-iliac  hollow.  The  iliac  fossa 
at  the  same  time  was  free  from  both  swelling  and  pain,  though  later  an 
abscess  was  detected  in  this  situation.  Both  the  lumbar  and  iliac  ab- 
scesses were  opened,  and  the  patient  sank  with  diarrhoea  and  hectic. 
There  was  no  jiost-mortem  examination,  but  it  was  evident  that  the  peri- 
nephritis was  of  uterine  not  renal  origin,  probably  by  way  of  the  iliac 
veins,  and  also  that  tiie  iliac  was  subsequent  to,  if  not  secondary  to,  the 
perirenal  abscess.  Pus  collected  around  the  kidney  might  easily,  as 
Trousseau  suggests,  pass  with  the  psoas  muscle  to  the  cellular  tissue  of 
the  iliac  fossa,  and  its  passage  in  the  contrary  direction  is  equally  easy. 

Among  the  extra-renal  causes  of  circumrenal  abscess  must  be  men- 
tioned, upon  the  authority  of  Trousseau,  one  wliich  rests,  like  some  of 
the  other  causes  which  receive  credence,  upon  inference  during  life 
rather  than  ascertainment  after  death.  Perforation  of  the  gall-badder  by 
a  calculus  was  believed  by  this  acute  observer  to  have  been  the  cause  of  sup- 
purative perinephritis  in  a  case  which  he  relates.  Severe  hepatic  colic,  in 
the  person  of  an  old  lady,  was  followed  by  sym})toms  of  acute  hepatitis, 
with  inflammation  of  the  gall-bladder  and  intense  pain  in  the  sub-hepatic 
region.  Then  there  was  fever,  and  severe  general  disturbance  of  the 
system;  when  all  at  once  the  pain  extended  to  the  right  renal  region, 
with  the  formation  of  an  abscess  there,  which  was  ultimately  opened, 
with  a  favorable  result.  In  Trousseau's  view  a  gall-stone  had  travelled 
through  an  ulceration  in  the  gall-bladder,  and  reached,  through  inter- 
vening adhesions,  the  perinephric  cellular  tissue.  Whether  or  no  the 
stone  traversed  the  considerable  interval  which  separates  the  gall-bladder 
from  the  renal  region,  it  is  at  least  clear,  as  the  narrator  observes,  that 
hepatic  colic  was  succeeded  by  circumrenal  abscess. 

Circumrenal,  or  deep  lumbar  abscess,  has  been  traced  to  hydatids, 
originating  probably  in  the  cellular  tissue.  In  a  case  recorded  by  Feron  ' 
these,  mingled  with  pus,  came  out  of  an  incision  which  had  been  made 
in  a  tumor  in  the  lumbar  region,  and  was  succeeded  by  recovery.  An 
abscess  in  the  adipose  tissue  about  the  kidney  has  been  known  to  ensue 
upon  removal  of  the  testicle  and  the  subsequent  application  of  a  ligature 
which  included  all  the  structures  of  the  spermatic  cord.  The  pus  was 
serous  and  foetid,  and  the  cellular  tissue  about  the  spermatic  cord  was 
infiltrated  with  the  same  matter.  It  was  supposed  that  the  secondary 
suppuration  was  due  in  this  case  to  the  irritation  of  the  nerve  and  the 
attendant  pain;  but  I  venture  to  think  it  more  probable  that  the  inflam- 
matory process  was  conveyed  by  mere  continuity  either  of  cellular  tissue 
or  of  venous  channels  from  the  place  of  the  ligature  to  the  place  of  the 
abscess.     I  have  seen  a  bulky  inflammatory  infiltration  of  the  whole 

'  Thesis,  by  M.  Feroii,  De  la  Perinephrite  primitive,  p.  42. 


28  SUPPURATIVE    PEKINKPIIUITIS. 

length  of  the  spermatic  cord  as  the  result  of  an  operation  involving  its 
lower  end. 

Mere  neuralgia  has  been  supposed  by  Trousseau,  though  perhaps  on 
insuflBcient  evidence,  to  be  efficient  as  a  cause  of  similarly  localized  su]i- 
puration.  It  has  been  traced  to  pyi^mia,  and  stated  to  have  followed 
ujion  other  febrile  conditions,  among  which  variola  and  typhus  have 
been  mentioned.  It  has  also  been  attributed  to  cold,  but  this  must  be 
regarded  as  more  than  doubtful. 

The  leading  facts  in  regard  to  the  symptoms  of  this  morbid  condition 
have  been  involved  in  the  preceding  account  of  its  nature  and  origin. 
Occurring  as  it  does  in  widely  different  circumstances,  it  takes  as  different 
shapes,  appearing  sometimes,  as  in  tiie  Plymouth  Dockyard  cases,  as 
part  of  a  severe  and  acute  febrile  disease,  at  other  times  with  the  slug- 
gish temper  of  lumbar  or  psoas  abscess  in  their  most  ciironic  forms.  In 
its  more  ordinary  kind  an  early  symptom  is  deep-seated  lumbar  pain, 
severe  and  lancinating  or  of  a  pricking  character,  with  tenderness,  possi- 
bly not  superhcial,  but  evident  upon  deep  handling  of  the  lumbar  region. 
With  this,  or  soon  after  it,  or  possibly  before  there  is  enough  of  either 
pain  or  swelling;  to  attract  notice,  comes  fever.  This  is  of  the  continued 
type,  with  evening  exacerbations  and  })Ossibly  nightly  sweatings,  like  tliu 
fever  of  tuberculosis,  which  it  often  resembles,  or  with  which  it  is  often 
associated.  Eigors  are  commonly  observed,  and  have  been  known  to 
occur  with  quotidian  regularity.  With  all  this  there  is  much  general 
illness  and  loss  of  api)etite,  and  of  flesh,  with  possibly  nausea,  vomiting, 
and  constipation.  Sooner  or  later  the  swelling  which  I  have  already 
referred  to  shows  itself  in  the  back,  filling  one  of  the  lumbar  hollows, 
giving  an  undue  sense  of  fulness  between  the  hands  placed  before  and 
behind,  and  finally  causing  the  brawny  or  doughy  state  of  surface  which 
indicates  the  approach  or  i)resence  of  pus.  The  posture  is  supine,  or,  if 
the  psoas  be  im])licated,  the  patient  may  sit,  as  described  by  Dr.  Bow- 
ditch,  on  one  gluteus,  and  have  the  bent  leg  characteristic  of  psoas  abscess. 

The  great  range  of  duration  Avhich  the  disorder  presents  is  sufficiently 
evident  from  what  has  been  already  said.  It  often  terminates,  as  in  the 
Plymouth  cases,  before  the  matter  has  had  time  to  present  externally. 
When  it  has  so  done,  the  course  of  disorder,  according  to  Feron,  is  still 
so  rapid  that  in  most  cases  the  abscess  is  completely  formed  and  evacuated 
within  three  months.  But  there  are  many  instances,  such  as  those  con- 
nected with  calculus,  in  which  the  abscess,  perhaps  sometimes  partially 
closing  and  opening  again,  may  extend  over  years,  or  last  indefinitely. 

The  urine  in  these  cases  has  relation  rather  to  the  presence  or  ab- 
sence of  some  of  the  causes  to  which  perinephritis  may  be  due  than  to 
the  affection  itself.  It  gives  no  evidence  of  the  presence  of  the  extra- 
renal suppuration,  but  may  declare,  by  blood  or  pus,  the  i)resence  of  a 
bruise  or  laceration  of  the  kidney,  or  of  stone  or  tubercle  within  it. 

Dr.  Duffin  collected  twenty-six  cases  to  ascertain  the  frequency  of 
urinary  complications.  ''Two  had  been  produced  by  an  injury  to  the 
loin,  and  had  bloody  urine;  six  had  free  pus;  two,  bladder  signs;  five, 
kidney  disease  without  bladder  signs;  and  no  less  than  twelve  had  no 
urinary  complication  whatever."' 

With  regard  to  the  treatment  of  circumrenal  abscess,  it  is  needless 
to  say  that,  if  once  the  matter  be  formed,  there  is  nothing  to  be  done  but 
to  jirovide  for  its  escape.     Incision  or  puncture  has  usually  been  practised 

■  Duffin.     Path.  Trans.,  vol.  xxiv.  p.  141. 


SUPPURATIVE    PERINEPHRITIS,  29 

in  the  loin,  an  opening  sometimes  having  been  effected,  at  the  bottom  of 
which  the  kidney  could  be  felt  with  the  finger.  The  average  of  success 
has  been  good,  and  would  have  been  better  were  it  not  that  the  suppura- 
tion is  dependent,  perhaps,  in  most  cases,  upon  incurable  disease.  Dr. 
Duflfin  tells  us  that  of  twenty  cases  he  collected,  in  which  abscess  in  this 
position  was  treated  by  early  puncture  through  the  loin,  the  operation  in 
two  was  followed  by  death — in  one  from  peritonitis — while  in  eighteen  it 
was  ".attended  with  a  considerable  modicum  of  success,"  in  twelve  with 
complete  recovery.*  It  is  to  be  presumed  that,  in  these  days  of  the 
aspirator,  puncture  by  its  means  will  sometimes  supersede  the  old  inci- 
sion, though  it  must  often  happen,  as  when  stone  or  tubercle  have  given 
origin  to  the  matter,  that  a  continuous  opening  is  inevitable.  As  one  of 
the  dangers  of  incision  must  be  mentioned  reiterated  ligemorrhage,  wliich 
proved  fatal  in  a  case  recorded  by  Parmentier.'* 

'  Duffin.     Case  of  perinephric  abscess,  Medical  Times,  September,  1870,  p.  362. 
See  also  conclusion  of  case,  Path,  Trans,,  vol.  xxiv.  p.  138. 
*  L"  Union  Medicate,  September,  1863,  p.  575. 


CHAPTEE  IV. 

THROMBOSIS  AND    EMBOLISM. 

Trombosis. 

When  the  blood  coagulates  in  its  own  vessels  and  there  remains, 
thrombosis  is  said  to  occur;  euiholism  when  the  vessels  are  obstructed  bj 
matters  brought  from  a  distance.  These  two  conditions  are,  as  will  be- 
seen,  different  in  their  cause,  in  their  seat,  in  their  progress,  and  in  their 
results.     Our  present  concern  is  with  thrombosis. 

It  has  long  been  recognized  that  the  blood  is  apt  to  coagulate  in  its 
vessels  during  life  as  well  as  after  death.  This  may  occur  in  many 
situations  and  circumstances;  sometimes  in  arteries,  more  often  in  veins. 
It  may  be  limited  to  one  vessel  or  one  system  of  vessels,  or  may  occur 
simultaneously  in  many  parts  of  tlie  body. 

Tiie  knowledge  that  clot  sometimes  forms  during  life  in  the  veins  of 
the  kidney  is  nothing  new  in  pathology,  though,  from  its  comparative 
infrequency,  it  occasionally  drops  out  of  notice,  to  reappear  like  an  old 
fashion  restored  with  the  freshness  of  novelty.  John  Hunter  has  de- 
scribed it  minutely. 

The  coagulation  takes  place,  almost  without  exception,  in  the 
veins,  not  in  the  arteries.  Dr.  Moxon  has  related  two  cases  in  which, 
after  injury,  clots  were  found  in  the  renal  vessels  of  both  kinds.  These 
cases,  which  in  many  respects  resemble  embolism  rather  than  throm- 
bosis, form  the  exception.  The  clotting  may  involve  one  gland  onl}',  or 
both  simultaneously.  A  kidney  in  which  general  thrombosis  has  re- 
cently occurred  is  increased  in  size  and  feels  unnaturally  hard.  In  sec- 
tion, it  is  seen  that  many  or  all  the  veins  which  can  be  followed  with 
the  naked  eye  are  occupied  with  coagulum,  which,  according  to  its  date 
and  degree  of  decolorization,  may  be  black,  brick-red,  or  buff.  These 
coagula  are  usually  continuous  through  many  subdivisions  and  ramifica- 
tions, and  sometimes  occupy  the  entire  venous  system  of  the  organ,  from 
the  vena  cava  to  the  finest  branches  which  can  be  reached  by  dissection. 
Beyond  these,  the  microscope  will  sometimes  show  that  the  minutest 
veins  and  capillaries  are  loaded  with  blood,  sometimes  even  to  bursting. 
The  clots  are  often  adherent  to  the  veins,  the  coats  of  which  remain 
natural. 

In  many  cases,  this  change  befalls  kidneys  which  have  previously  been 
the  seat  of  disease  whereby  the  circulation  through  them  has  become 
impeded.  Sometimes,  besides  the  renal  system  of  veins,  those  of  the 
lower  extremities  and  the  portal  vein  are  similarly  affected,  while  clots 
have  also  been  found  at  the  same  time  in  the  heart  and  other  situations. 

The  rapidity  with  v/hich  the  disease,  when  general  throughout  the 
kidneys,  proves  fatal,  gives  no  time  for  such  slow  degenerative  changes 
as  occur  in  coagulum  in  less  lethal  situations.     When,  however,  it  has 


THKOMBOSIS    AND    EMBOLISM.  3L 

been  limited  to  one  kidney,  or  to  a  part  of  one  kidne}^,  a  process  of  fatty 
softening  occurs,  such  as  is  very  common  in  connection  with  an  embolic 
block.  In  the  case  of  a  man  who  died  at  St.  George's  Hospital  with 
thrombosis,  evidently  of  old  date,  affecting  the  renal,  supra-renal,  and 
iliac  veins,  the  anterior  half  of  the  affected  kidney  was  occui)ied  by  a 
soft  pinkish  mass,  of  the  consistence  of  putty,  which  under  the  micro- 
scope ai^peared  to  consist  mainly  of  oil-globules.' 

Coagulation  of  the  blood  during  life  may  be  produced  by  inequality 
or  change  of  character  in  the  surfaces  over  which  it  flows,  by  retarda- 
tion of  its  current,  or  by  a  morbid  change  in  the  blood  itself.^ 

We  often  see  coagulation  determined  by  alterations  of  surface  in  the 
collection  of  fibrin  upon  valves  and  arterial  surfaces;  but  in  the  kidney, 
where,  apart  from  embolism,  it  takes  place  especially  in  the  veins,  we 
seldom  see  the  operation  of  this  cause.  With  regard  to  this  organ,  it 
may  be  stated  that  the  causes  of  coagulation  are  mainly  of  two  kinds: — 

1.  Retardation  of  the  circulation  by  narrowing  of  the  vessels. 

2.  Morbid  coagulability  of  the  blood. 

Considering,  first,  narrowing  of  the  vessels  as  a  cause  of  renal  throm- 
bosis, this  occurs  in  its  simplest  form  when  the  veins  are  narrowed  and 
their  current  obstructed  by  morbid  growths  outside  them.  A  case  of  tins' 
kind  is  reported  by  Mr.  Sibley,  in  the  "  Transactions  of  the  Pathological 
Society,"^  in  which  coagula  were  formed  in  the  vena  cava,  the  veins  of 
both  up])er  and  lower  limbs,  and  the  renal  veins,  in  consequence  of  the 
infiltration  of  the  tissues  surrounding  the  inferior  cava,  iliac,  and  axillary 
veins,  by  a  cancerous  growth. 

We  see  the  same  result  produced  by  vascular  constriction  of  a  differ- 
ent kind,  in  the  frequency  with  which  renal  thrombosis  is  associated  with 
chronic  disease  of  the  kidney.  This  must  be  in  part,  though,  as  I  shall 
presently  show,  not  entirely,  attributed  to  the  hindrance  which  occurs  to 
the  circulation  from  the  encroachment  of  fibroid  growth,  the  pressure  of 
distended  tubes,  or  the  lardaceous  thickening  of  the  arterial  coats.  Under 
these  conditions  the  blood  reaches  the  veins  with  its  velocity  unnaturally 
diminished,  and  is  accordingly  disposed,  until  it  reaches  the  main  stream 
of  the  vena  cava,  to  coagulate.  The  degree  to  which  the  renal  vessels 
are  obstructed  by  disease  may  be  easily  demonstrated  by  the  simple  expe- 
dient of  allowing  water  to  flow  into  the  renal  artery  of  a  healthy  and  of  a 
granular  kidney.  It  will  be  found  that  water  traverses  the  diseased 
organ  with  extraordinary  slowness  compared  with  the  healthy  one.* 

Independently  of  local  or  organic  alterations  coagulation  may  depend 
upon  an  unnatural  tendency  of  the  blood  to  deposit  fibrin.  This  is  fully 
as  important  in  relation  to  renal  thrombosis  as  narrowing  of  the  vascular 
channels.  There  are  many  conditions  of  system  in  which  the  blood 
is  apt  to  congeal  where  its  current  is  slowest.  Such  a  state  appears 
to  belong  to  many  conditions  of  j^rostration,  exhaustion,  and  fe- 
brile disturbance.  Under  such  general  influences  coagula  are  apt 
to  form  simultaneously  in  more  than  one  system  of  vessels,  the  renal 
clotting  being  associated  with  a  similar  change  elsewhere.     The  renal 

'  Reported  by  Dr.  J.  W.  Ogle  in  the  Patli.  Trans,  vol.  vii.  p.  177. 

"^  I  have  discussed  the  causes  of  the  coagulation  of  blood  in  the  living  body  in 
more  detail  in  a  paper  upon  the  Coagulation  of  Blood  in  the  Cerebral  Arteries, 
St.  George's  Hospital  Reports,  vol.  i.  p.  257. 

^  Path.  Trans,  vol.  ix.  p.  128. 

■•  I  have  related  some  observations  of  thia  kind  in  the  Med,  Chir.  Trans,  for 
1860,  p.  242. 


32  THROMBOSIS    AND    EMBOLISM. 

veins  sometimes  share  with  the  femoral  in  the  coagulating  process  which 
js  apt  to  follow  parturition.  A  young  woman,  who  had  been  delivered 
six  weeks  before,  was  brought  into  the  liospital  with  plilegmasia  dolens 
affecting  both  lower  extremities.  After  death,  which  occurred  nine  days 
later,  ooagula  of  distinctly  «M/e-j//or/!e?;i  character  were  found  generally 
distributed  in  the  veins  of  the  uterine  organs,  pelvis  and  lower  extremi- 
ties, and  also  in  those  of  the  right  kidney.  Renal  thrombosis  has 
been  known  to  occur  in  other  states  of  systemic  disturbance,  as  in 
typhus. 

The  febrile  condition,  of  whatever  nature  it  be,  appears  to  be  a  possi- 
ble cause  of  coagulation;  that  this  could  be  produced  experimentally  by 
an  increased  temperature  Avas  long  ago  shown  by  Hewson.  It  is  not 
needful, .however,  to  discuss  the  causes  of  thrombosis  in  general;  its  as- 
sociation with  antemia  and  prostration,  Avith  gout  and,  though  rarely, 
with  rheumatism,  is  well  known.  On  whatever  cause  it  depend,  the  kid- 
ney may  be  its  location.  Finally,  as  a  cause  of  thrombosis  which  is 
directed  especially  upon  the  kidney  because  it  is  usually  associated  with 
structural  disease  of  that  organ,  must  be  mentioned  the  effect  upon  the 
blood  of  long  continued  albuminous  discharges,  whether  purulent  or  of 
the  nature  of  all)uminuria. 

By  such  means  we  must  infer  that  the  composition  of  the  blood  is 
altered  by  the  withdrawal  of  its  albuminous  part,  leaving  the  coagulable 
element  in  relative  excess.  Thus  we  may  account  for  the  frequent  occur- 
rence of  thrombosis  in  connection  with  lardaceous  disease.  The  lardace- 
ous  change  and  the  morbid  coagulability  of  blood  result  in  common  from 
exhausting  discharges.  When  the  kidneys  themselves  are  the  seat  of 
chronic  disease,  involving  the  loss  of  albumin,  they  are  exposed  to  a 
double  chance  of  thrombosis.  The  blood  in  their  vessels,  as  elsewhere,  is 
rendered  morbidl}'  coagulable  by  the  drain;  their  circulation  is  impeded 
by  local  disei^se.  This  co-operation  of  obstruction  with  coagulability  ac- 
counts for  the  frequency  of  thrombosis  in  connection  with  chronic  albu- 
minuria. 

The  symptoms  of  this  fatal  alteration  are  not  sufficiently  definite,  or 
are  too  often  masked  by  the  results  of  antecedent  disease,  to  lead  to  its 
detection  during  life;  but  the  salient  points  of  its  clinical  history  can  be 
discerned  by  following  back  the  history  of  the  cases  in  which  it  has  been 
discovered.  Originating,  as  it  does,  in  connection  with  exhausting  dis- 
ease, albuminuria,  or  some  febrile  state,  its  especial  manifestations  are 
apt  to  be  overlooked  or  misinterpreted. 

From  the  fact  that  instances  of  general  renal  thrombosis  seldom  come 
to  view,  as  more  partial  clots  often  do,  in  a  state  of  degeneration  or  change 
bearing  record  of  the  handiwork  of  time,  but  the  condition  is  nearly 
always  recent  at  the  time  of  death,  we  must  infer  that  it  is  usually  rapidly 
fatal. 

The  condition  of  the  patient  is  generally,  either  from  the  disease  itself 
or  its  antecedents,  one  of  extreme  prostration.  The  urine  aiipears  to  be 
highly  albuminous,  sometimes  bloody,  and  much  reduced  in  (juantity,  as 
if  from  any  other  cause  the  kidneys  were  in  a  state  of  intense  injection. 
If  the  arteries  as  well  as  the  veins  are  generally  obstructed,  there 
may  be,  or  rather,  if  the  condition  is  complete,  there  must  be,  total 
suppression.  The  presence  of  albumin  or  blood  in  the  urine  in  con- 
nection with  thrombosis  is  sometimes  equivocal,  as  when  this  con- 
dition ensues  upon  renal  disease;  but  it  is  equally  to  be  observed 
when  the  kidneys  have  been  previously  healthy,  as  in  the  instance  re- 


THROMBOSIS    AND    EMBOLISM.  33 

lated  by  Mr.  Pick.     Eenal  pain  has  not  been  noticed  in  connection  with 
this  disorder. 

Limited  or  general  oedema  is  necessarily  often  present  with  it,  as  the 
iliac  veins  may  share  in  the  condition,  or  kidney  disease  cause  it;  but  it 
does  not  appear  that  this  symptom  has  been  traced  to  renal  thrombosis 
pure  and  simple,  though  such  a  result  is  probable. 

Recovery  may  ensue  when  the  renal  coagulation  has  been  only  partial. 
An  instance  has  been  given  in  whicli  thrombosis  affecting  one  kidney  only 
was  found  after  death  in  a  state  which  sufficiently  proved  that  it  had 
occurred  a  long  time  before  (p.  31).  It  is  probable  that  partial  renal 
coagulation  would  produce  symptoms  resembling  those  which  belono-  to 
the  more  common  and  more  easily  recognized  condition  of  embolism. 
The  infrequency  of  renal  thrombosis  is  such  that  one  may  wait  long  for 
opportunities  of  observation. 

As  this  affection  of  the  kidney  has  hitherto  escaped  recognition  during 
life,  the  consideration  of  its  treatment  would  seem  superfluous.  Should 
the  condition  be  detected,  it  is  obvious  that  drugs  which  lessen  coagula- 
bility, of  which  the  fixed  alkalies  are  the  most  trustworthy,  would  be 
called  for. 

Embolism. 

The  impaction  of  erratic  masses  of  fibrin  in  the  vessels — embolism, 
as  it  is  termed — has,  since  the  observations  of  Kirkes  and  Virchow,  been 
clearly  distinguished  from  the  fixation  of  coagulum  in  the  place  of  its 
formation,  which  is  known  as  thrombosis.  The  results  of  embolism  vary 
in  different  organs,  with  the  distribution  of  the  arteries  and  the  proper- 
ties of  the  tissue,  but  they  are  generally  easily  recognizable,  and  nowhere 
])resent  more  striking  and  constant  characters  than  those  of  the  well- 
known  "  fibrinous  block,"  which  is  the  form  they  take  in  the  kidneys. 
Tiie  left  cavities  of  the  heart  furnish,  as  would  be  supposed,  the  ordinary 
source  of  the  emboli  which  enter  the  kidney.  Whenever  accumulated, 
fibrin  is  broken  from  the  valves  or  walls,  an  accident  whicli  is  of  con- 
tinual occurrence  in  cardiac  disease,  more  especially  in  endocarditis  of 
recent  date,  the  fragment  is  liable  to  be  swept,  by  their  copious  and 
direct  arterial  supply,  into  one  or  other  kidney. 

There  is  certainly  no  organ  in  which  the  results  of  embolism  are  so 
often  noticed  as  in  this,  though  it  would  be  too  much  to  assert  that 
there  is  no  position  in  which  they  so  frequently  occur. 

The  earliest  alteration  in  the  kidney  which  declares  to  the  naked  eye 
that  loose  fibrin  has  been  swept  into  its  artery  is  circumscribed  injection 
or  extravasation.  Of  this  there  may  be  one  or  many  patches,  each  patch 
indicating  a  separate  lodgment. 

Often  a  patch  or  ring  of  injection  of  considerable  size  is  found  upon 
the  surface,  or,  as  luippened  in  a  case  in  which  I  detected  the  change  at 
a  very  early  period,'  a  congested  circle  about  as  large  as  a  sixpence  was 
surrounded  by  a  white  margin.  Later  the  appearances  become  more 
characteristic.  Hard,  dense,  straw-colored  edges,  bordered  by  vivid  con- 
gestion, are  seen  in  section,  the  point  of  the  wedge  being  in  a  cone, 
the  diverging  lines  crossing  the  cortex,  the  base  abutting  upon  the  cap- 
sule. When  the  wedges  or  cones  are  small,  as  is  the  case  when  the  fibrin 
is  confined  to  the  territory  of  one  of  the  smaller  arteries,  the  arrangement 
as  described  is  distinctly  seen.     More  rarely  the  change  involves  a  large 

'  Pathological  Transactions,  vol.  xiii,  p.  46. 


34 


THROMBOSIS    AND    EMBOLISM. 


proportion  of  the  organ,  often  at  one  end;  the  conical  disposition  is  then 
necessarily  obscured.  As  much  as  a  third  of  the  gland,  or  even  more, 
may  be  thus  transformed,  the  fibrin  filling  one  of  the  larger  subdivi- 
sions of  the  renal  artery,  and  permeating  the  whole  of  its  field  of  distri- 
bution. 

Under  these  circumstances,  a  careful  dissection  will  often  show  that 
the  artery  leading  to  the  block  is  plugged  with  fibrin;  this,  however,  is 
not  always  the  case.  Unless  the  intruded  material  is  very  abundant,  the 
minute  vessels  fill  first.  The  blocks  are  so  different  in  color  and  texture 
from  the  surrounding  tissue  that  they  look  like  masses  foreign  to  the 


\^'     '' 


Embolic  block  in  kidney,  the  obstruction  extending  into  renal  artery. 
(From  a  drawing  at  St.  George's  Hospital.; 

kidney,  and  inserted  into  it.  A  close  examination,  nowever,  even  with 
the  naked  eye,  will  often  reveal  pale  lines  and  spots,  which  show  that  the 
vessels  and  Malpighian  bodies  still  hold  their  position,  though  they  have 
lost  their  color.  The  blocks  are  sometimes  raised  upon  the  surface,  ow- 
ing to  the  distention  of  their  vessels  by  the  intruding  material. 

As  time  goes  on,  the  vivid  injection  around  them  fades,  their  light 
bright  color  becomes  duller  and  yellower,  the  resilient  hardness  gives  way 
to  a  puffy,  greasy  friability;  they  no  longer  protrude  upon  the  surface, 
but  they  shrink  as  they  soften,  and,  through  stages  of  fatty  transforma- 
tion and  absorption,  disappear,  leaving  a  depressed  indurated  cicatrix  as 
the  only  record  of  their  existence.     If  the  infiltration  has  been  extensive. 


THROMBOSIS    AND    EMBOLISM.  35 

a  large  proportion  of  the  organ  may  be  destroyed  by  this  means.  Dr. 
Van  der  Byl  describes  a  kidney  from  a  case  in  which  embolic  blocking 
had  occurred  in  many  organs,  which  "weighed  only  an  ounce  and  a  half; 
it  was  much  deformed,  and  consisted  for  the  most  part  of  firm  yellowish 
substance,  very  little  of  the  renal  structure  remaining  free  from  deposit."^ 
It  was  clear,  from  tlie  history  and  surroundings  of  the  case,  that 
this  extreme  destruction  of  renal  substance  had  been  produced  emboli- 
cally. 

The  microscope  enables  us  to  add  a  few  particulars.  At  an  early  stage 
there  is  no  change  in  the  kidney  save  blocking  of  the  vessels  in  a  limited, 
area,  and  sanguineous  distention  of  those  around.  The  obstructing  ma- 
terial is  amorphous  or  finely  granular,  sometimes  blood-tinged  or  mixed 
with  corpuscles.  It  appears  to  consist  mainly  of  comminuted  fibrin.  It 
is  found  in  the  arteries  and  capillaries,  not  in  the  veins.  The  material 
evidently  penetrates  the  smaller  arteries  with  facility,  but  cannot  get 
through  the  capillaries.  In  the  capillaries,  therefore,  or  in  the  smallest 
arteries,  the  arrest  takes  place,  and  the  intruded  material  accumulates, 
behind  the  stoppage,  mounting,  according  to  its  abundance,  in  larger 
and  larger  vessels.  The  straight  vessels  of  the  cones,  and  those  which 
pass  thence  to  the  cortex,  are  more  often  blocked  than  the  Malpighiaii 
capillaries.  The  clot  passes  more  readily  into  the  branches  of  the  renal 
artery  which  enter  the  cones  directly  than  into  those  which  supply  the 
Malpighian  bodies.  The  latter  are  perhaps  less  easily  entered,  given  oR 
as  they  are  at  an  abrupt  angle.  The  knowledge  that  the  cones  receive 
vessels  directly  from  the  renal  artery  enables  us  to  understand  facts  con- 
nected with  renal  disease  which  would  be  otherwise  incomprehensible. 
It  used  to  be  thought  that  all  the  blood  of  the  renal  artery  passed  through 
the  Malpighian  bodies  before  going  to  the  tubes.  On  such  a  supposition 
the  disposition  of  fibrinous  blocks  is  inexplicable.  Did  such  a  disposition 
of  vessels  exist,  it  would  be  hard  to  explain  the  fact,  often  observed,  that 
fibrin  injected  by  the  arteries  should  be  found  in  the  intertubular,  wliile 
none  is  to  be  seen  in  the  Malpighian  capillaries.  The  coarse  material 
appears  to  be  unable  to  pass  through  vessels  of  the  capillary  size,  and 
must  necessarily  be  arrested  in  the  Malpighian  bodies,  if  it  reach  them 
first.  Dr.  George  Johnson*  has  been  led  by  this  imperfect  view  of  the 
renal  circulation  to  maintain  that  the  blocks,  which  are  generally,  and, 
as  I  have  endeavored  to  show,  truly,  regarded  as  embolic,  are  the  result 
of  the  coagulation  of  blood  w  situ.  This  view,  however,  is  refuted  by 
the  exemption  of  the  veins  from  obstruction,  by  the  abrupt  limitation  of 
each  block  to  the  territory  of  its  own  artery,  and  by  their  invariable 
association  with  fibrinous  deposits  in  the  heart  or  elsewhere  in  the  course 
of  the  blood  which  flows  to  the  kidney.  Coagulation  i7i  situ  occurs,  as 
has  been  shown,  in  different  circumstances,  mainly  in  the  veins,  and 
without  abrupt  limitation. 

In  recent  blocks  the  only  change  is  in  the  contents  of  the  vessels;  the 
stationary  structures  within  the  block  soon,  however,  along  with 
the  contents  of  the  vessels,  undergo  degenerative  transformations.  The 
impacted  fibrin  rapidly  becomes  fatty,  and  a  similar  alteration  affects 
the  tubes  and  other  renal  elements.  General  fatty  disintegration  ensues 
within  the  affected  region,  the  broken-down  tissues  are  absorbed,  until  at 

'  Path.  Trans,  vol.  vii.  p.  168. 

'  "  On  the  Minute  Anatomy  of  the  so-called  Fibrinous  Deposits  in  the  Kid- 
neys," Path.  Trans,  vol.  ix.  p.  305. 


^6  THRiniBOSIS    AND    EMBOLISM. 

last  only  the  puckered  cicatrix  remains,  which  has  been  referred  to  in 
connection  witli  the  naked-eye  apjjearances. 

Tlie  renal  changes  which  have  been  described  necessarily  result,  as  a 
rule,  from  disease  of  the  left  side  of  the  heart.  Rheumatic  endocarditis 
often  gives  rise  to  tliem,  as  also  do  more  chronic  valvular  affections,  i)ar- 
ticularly  if  they  be  accompanied  Avith  the  deposition  of  fibrin  upon  the 
iiuricular  or  ventricuhir  wall.  The  blocking  of  the  kidney,  if  it  occur 
alone,  is  seldom  of  much  clinical  importance;  unless  extensive,  it  often 
escapes  recognition  during  life,  the  symptoms  being  obscured  by  the 
otiicr  results  of  the  cardiac  disease  in  whicii  it  takes  its  origin.  The  im- 
paction may  be  marked  by  shivering  and  succeeded  by  fever,'  but  these 
])erhaps  more  often  occur  when  the  dissemination  is  general  or  Avidely 
distributed  tluin  Avhere  it  is  only  renal.  The  symptoms  of  the  renal 
localization  are,  however,  tolerably  well  marked,  and  would  no  doubt  be 
more  often  found  were  they  more  generally  understood.  The  urine  be- 
comes suddenly  albuminous,  often  bloody,  and  at  the  same  time  there  is 
sudden  and  sometimes  violent  pain  in  one  or  the  other  renal  region. 
With  this,  should  the  affection  of  the  kidney  be  extensive,  there  may  be 
vomiting  and  more  or  less  collapse.  When  the  impaction  is  of  small  ex- 
tent, little  further  may  occur  than  a  suddenly  albuminous  state  of  the 
urine,  which  is  usually  of  high,  or  at  least  of  unaffected,  specific  gravity. 
It  contains,  besides  albumin,  blood-corpuscles  and  numerous  tube-casts. 
The  casts  are  of  moderate  diameter,  and  are  more  often  simply  fibrinous 
than  of  any  other  kind.  It  is  probable  that  the  change  in  the  urine  is 
not  due  to  any  general  disturbance  of  secretion  throughout  the  kidney, 
but  simply  to  a  species  of  circumscribed  nephritis  in  the  block  itself  and 
its  intensely  congested  vicinity. 

The  urine  gradually  resumes  its  natural  character;  the  pain,  should 
there  have  been  any,  is  of  short  duration,  and,  after  a  few  days  or  weeks, 
all  sym])toms  of  the  disturbance  have  passed  away.  The  block  is  still  in 
the  kidney,  but  it  is  no  longer  a  source  of  irritation. 

Blocking  of  other  systems  of  vessels,  particularly  of  the  cerebral,  often 
occurs  simultaneously  with  the  renal  impaction,  and  proportionately 
aggravates  the  symptoms.  Cerebral  embolism  especially  is  ai)t  to  be 
attended  not  only  with  cerebral  disturbance,  but  with  severe,  and  often 
rapidly  fatal  febrile  prostration.  Such  symi)toms,  however,  do  not  appear 
to  occur  Avhen  the  kidney  only  is  affected. 

The  account  of  renal  embolism  would  not  be  complete  without  men- 
tion of  a  result  which  is  occasionally  produced  in  the  renal  as  well  as  in 
other  arteries  by  embolic  obstruction. 

Apparently  chieily  in  consequence  of  the  hurt  inflicted  upon  the  vessel 
by  the  lodgment,  aneurism  in  the  place  of  it  has  been  known  to  occur  in 
the  arteries  of  the  brain,  of  the  limbs,  of  the  lungs,  of  the  heart,  and  of 
the  kidneys. 

With  regard  to  the  treatment  of  embolic  obstruction  of  the  renal 
vessels  little  need  be  said.  The  question  resolves  itself  into  the  larger 
inquiry,  the  treatment  of  cardiac  disease.  Generally  speaking,  the  re- 
sults of  embolism  in  the  kidney  are  not  serious  or  lasting.  The  block 
is  rapidly  disintegrated  and  absorbed,  and  its  jdace  knows  it  no  more. 
When,  as  sometimes  happens,  severe  pain  results  from  the  impaction, 
opiates,  by  injection  or  otherwise,  may  be  resorted  to;  beyond  this,  treat- 
ment of  the  affection  may  be  left  to  the  secret  workmanship  of  nature. 

'  See  cases  reported  by  W.  H.  Dickinson,  Brit.  Med.  Journ.  May  21st,  1881. 


CHAPTER    V. 
GENERAL  EELATIONS  OF  RENAL  TUMORS. 

The  subject  may  be  conveniently  taken  in  two  parts,  the  tirst  dealing- 
with  the  general  relations  of  renal  enlargements,  whatever  be  their 
nature;  the  second  with  morbid  formations,  whether  attended  or  not  with 
obvious  tumefaction. 

Swellings  of  the  kidney  are  perhaps  more  often  the  subjects  of  errors; 
of  diagnosis  than  those  of  any  other  organ,  which  as  frequently  presents; 
itself  in  the  guise  of  an  abdominal  tumor.  Doubtfud  tumors  are  apt  to 
present  the  riddle  of  their  nature  in  the  shape  of  the  question,  ''Is  it 
renal  or  is  it  not?"  This  answered,  the  rest  is  clear.  To  suppose  a 
solid  renal  tumor  to  be  splenic,  or  a  hollow  one  to  be  ovarian,  are  errors 
of  not  infrequent  occurrence;  while  a  list  of  the  enlargements  which  have 
either  been  erroneously  supposed  to  be  renal,  or  for  which  renal  swellings^ 
have  been  mistaken,  would  be  little  short  of  a  complete  catalogue  of 
abdominal  tumors.  It  would  include  tumors  in  connection  with  the 
liver  and  with  the  uterus;  enlargements  of  the  supra-renal  bodies,  of  the 
lumbar  glands,  and  of  the  mesenteric  glands;  intestinal  accumulations, 
abscesses,  especially  such  as  are  in  connection  with  the  vertebra,  and, 
strange  to  say,  ascites,  for  which  not  only  have  renal  cysts  been  mis- 
taken, but  even  solid  tumors.  In  a  child  three  years  of  age  a  fluctuating 
renal  sarcoma  was  thus  misinterpreted.' 

The  marks  whereby  renal  tumors  are  to  be  recognized  are  mainly  ana- 
tomical. It  is  not  necessary  to  say  that  the  kidneys  extend  from  the 
front  of  the  eleventh  rib  to  near  the  crest  of  the  ilium,  the  right 
coming  a  trifle  lower  down  than  the  left.  They  are  supported  behind 
by  the  flat  muscles  of  the  abdominal  wall,  which  are  themselves  backed 
up  by  the  great  erectors  of  the  spine,  and  their  attachments  to  the 
lumbar  vertebrae.  In  front  they  are  separated  only  by  the  peritoneum, 
and  partially  by  the  large  bowel,  from  the  abdominal  cavity,  so  tliat, 
should  they  become  the  subjects  of  swelling,  their  bulk  will  probably 
come  forwards  as  the  direction  of  least  resistance.  It  is  only  in  excej)- 
tional  circumstances  that  a  renal  tumor  obtrudes  in  the  loin  as  more 
than  an  indistinct  fulness;  this,  indeed,  may  be  the  only  backward  mani- 
festation of  a  swelling  which  may  fill  a  considerable  portion  of  the  ab- 
dominal cavity.  But,  however  apt  to  encroach  upon  this  cavity  and 
confuse  themselves  with  the  organs  which  lie  within  it,  there  are  certain 
characteristics  which  cleave  to  them  as  post-peritoneal.  One  is  the 
direction  of  such  diseases  as,  like  cancer  and  abscess,  advance  by  con- 
tiguity from  the  kidney  to  the  other  organs  placed  with  it  behind  the 
serous  partition.  We  see  this  in  the  invasion  of  the  vertebras  by  adjacent 
renal  cancer,  and  in  the  erosion  and  possible  penetration  of  the  vertebral 

'  St.  George's  Hospital  Museum  Catalogue,  Series  xi.  Prep.  38. 


38  GENERAL    RELATIONS    OF    RKNAL   TUMORS. 

column  by  pus  of  renal  origin.  In  the  next  place,  renal  tumors  so  seldom 
fail  to  have  bowel  in  front  that  the  exceptions  have  the  interest  of  lusns 
oiatnrm. 

To  state  the  rule  before  the  exceptions,  the  ascending  colon  usually 
is  to  be  found  in  front  and  towards  the  inner  side  of  a  right  renal  tumor, 
the  descending  colon  in  fi'ont  of  one  belonging  to  tlie  loft  side  ;  besides 
■which  tumors  of  either  ]<iduey  are  apt  to  have  coils  of  small  bowel  before 
them,  overlying  especially  tlieir  inner  half,  unless  they  have  attained 
such  dimensions  as  to  l)e  widely  in  contact  with  tlie  abdominal  wall. 

The  position  of  the  duodenum  in  front  of  the  right  kidney  would  lead 
one  to  expect  that  it  would  still  be  in  front  of  a  renal  tumor.  It  docs 
not  appear,  however,  to  be  carried  straight  forward.  In  Dr,  Hillier's 
case  of  right  hydronephrosis  referred  to  at  p.  10-4, this  portion  of  the  in- 
testine was  adherent  to  tlie  upper  and  left  sitle  of  the  cyst;  and  in  an 
instance  of  tul)ercular  enlargement  of  the  right  kidney  recently  under 
my  care,  the  duodenum  was  found  (see  fig.,  p.  90)  after  death  closely 
adherent  to  the  inner  side  of  the  organ,  while  the  ascending  colon  tra- 
versed its  front. 

But  so  pertinaciously  does  the  colon  on  each  side  hold  to  its  position 
as  to  be  almost  never  absent  from  the  front  of  a  renal  tumor,  and  can  be 
here  recognized,  even  when  flattened  and  non-resonant,  by  the  sensation 
which  it  gives  as  it  rolls  under  the  lingers.  Bowel  is  never  found  in 
front  of  an  enlarged  sjileen,  and  seldom  before  an  enlarged  liver.  With 
regard  to  liver,  the  rule  is  that  under  enlargement  the  front  edge  falls 
like  a  shutter  immediately  behind  the  wall  of  the  belly,  without  inter- 
vening intestine  ;  but  exception  to  this  rule  may  occur  when  either  the 
shape  of  the  liver  is  much  altered  by  disease  or  the  abdominal  wall  much 
protruded  by  ascites.  The  two  causes  may  concur,  and  bowel  be  abun- 
dantly resonant  in  front  of  a  hepatic  tumor,  when  the  liver,  as  with  hy- 
pertrophic cirrhosis,  is  made  globular  at  the  same  time  thatit  is  increased 
in  bulk,  so  that  as  it  passes  downwards  it  slopes  away  from  the  abdominal 
wall,  and  also  sometimes  when  cancerous  masses  protrude  from  its  under 
surface. 

The  rule  that  a  renal  tumor  has  bowel  before  it  is  not,  as  has  been 
implied,  Avithout  exception.  The  colon  on  the  right  side  is  not  so  closely 
connected  with  the  kidney  as  on  the  left,  and  a  renal  growth  has  been 
knitwn  to  insinuate  itself  between  the  liver  and  ascending  colon,  and  to 
push  the  latter  down  instead  of  carrying  it  in  front. 

Again,  a  renal  tumor,  if  very  large,  may  carry  the  bowel  with  it  in 
its  advance  towards  and  beyond  the  median  line,  so  that  the  colon, 
though  still  in  front  of  the  tumor,  is  not  on  its  own  side  of  the  body. 
Another  exception  may  be  with  a  floating  kidney,  as  it  is  called,  or  a  kid- 
ney which  enjoys  the  liberty  of  a  mesentery.  This  may  be  uncovered  by 
bowel  of  any  kind,  and  lie  immediately  under  the  surface,  like  a  f^cal 
accumulation,  for  which  indeed  a  healthy  floating  kidney  may  be  easily 
mistaken.  A  floating  kidney  may  become  the  seat  of  tumor,  or,  per- 
haps, more  often  a  diseased  kidney  may  float.  A  jiaticnt  underwent  an 
operation  in  the  Middlesex  Hospital  for  the  removal  of  a  tumor,  which 
was  thought  to  be  ovarian.  It  bulged  forwards  below  the  umbilicus,  on 
the  left  of  the  median  line,  and  could  be  felt  also  in  the  left  lumbar  re- 
gion, which  was  dull  on  percussion,  as  compared  with  the  other  side. 
The  uterus  was  in  its  natural  position,  and  freely  movable,  independently 
of  the  tumor.  The  renal  origin  of  the  disease  was  first  suggested  in  the 
course  of  the  operation,  when  it  was  discovered  that,  though  not  closeld 


GENERAL  RELATIONS  OF  RENAL  TUMORS,  39 

bound  to  the  lumbar  region,  the  mass  was  covered  by  peritoneum  in  such 
a  manner  as  to  forbid  its  excision.  After  death  it  was  found  that  the 
growtli  belonged  to  the  left  kidney,  though  it  had  sprung  from  the  cel- 
lular tissue  of  the  hilum  rather  than  from  the  glandular  substance.  It 
had,  like  many  other  renal  tumors,  an  encephaloid  appearance  and  a  sar- 
comatous structure.  The  peculiarity  of  the  case,  and  i)robably  the  source 
of  error,  was  in  the  situation  of  the  tumor  wholly  in  front  of  the  bowel. 
The  kidney,  together  with  the  growth  within  its  capsule,  "was  loosely 
tethered  to  the  renal  position  by  a  "mesentery,"  which  permitted  the 
mass  to  come  so  far  forward  that  the  descending  colon  and  sigmoid  iioxure, 
with  the  rest  of  the  bowels,  lay  behind  it.  Looking  at  the  case  with  pos- 
thumous wisdom,  it  is  easy  to  say  that  the  natural  position  and  mobility 
of  the  uterus,  together  with  the  ha-ge  amount  of  lumbar  dulness  for  the 
size  of  the  tumor,  luul  it  been  ovarian — it  was  about  four  inches  in  dia- 
meter— might  have  raised  doubt  as  to  its  ovarian  nature.' 

Kenal  swellings,  wlien  small,  are  usually  confined  to  their  own  side  ; 
when  large,  they  encroach  upon  the  other  ;  when  very  large,  they  appear 
to  fill  botli,  but  seldom  so  equally  but  that  with  care  a  distinction  can  be 
discerned.  When  tlie  kidney  is  distended  with  liquid,  as  in  hydrone- 
phrosis, it  may  occupy  the  whole  belly;  or,  short  of  this,  much  of  its 
bulk  may  cross  tlie  median  line  as  if  it  were  ovarian,  which  in  many  in- 
stances it  has  been  supposed  to  be  ;  it  has  even  jxisseJ  as  ascites,  and  that 
in  careful  and  i)ractised  hands.  A  collection  of  i)us  within  the  renal 
cavity  may  transgress  the  median  line,  as  in  a  case  under  my  own  obser- 
vation in  which  the  outline  as  felt  during  life  is  shown  at  page  41. 

Even  a  solid  renal  growth  may  be  of  such  a  size  compared  to  the  ab- 
domen as  to  occupy  the  greater  part  of  it  with  little  distinction  of  side, 
as  in  an  instance  already  alluded  to,  in  which  a  fluctuating  renal  sarcoma 
was  mistaken  for  ascites.  The  growth  was  from  the  concavity  of  the 
kidney,  so  that  its  line  of  advance  was  towards  the  vertebral  column  and 
the  opposite  side."  And  where  a  solid  renal  tumor  has  been  relatively 
smaller,  I  have  known  some  part  of  it,  or  of  the  parent  organ — the  lower 
end  of  the  latter  in  particular — to  be  thrust  downwards  and  forwards,  so 
as  to  infringe  upon  the  abdominal  wall  not  only  much  below  its  proper 
position,  but  across  the  median  line. 

The  accompanying  outlines  Avill  show  the  positions  in  which  renal 
enlargements  usually  manifest  themselves.  Win  e  small,  they  are  evi- 
dent only  on  deep  pressure,  and  in  tlie  })roper  renal  jiosition.  Sir  William 
Jenner  long  ago  told  us  how  to  estimate  the  size  of  the  kidney  by  touch, 
a  more  sure  mode  than  percu--sion.'  One  hand  is  to  be  })laced  behind  the 
patient  underneath  the  last  riband  just  outside  the  great  lumbar  muscles, 
the  other  in  front  just  over  tlie  hand  behind,  if  in  the  right  side  immedi- 
ately under  the  liver;  thus  the  kidney  lies  between  the  two  sets  of 
fingers,  and  by  diverting  the  patient's  attention  so  as  to  to  secure  abdo- 
minal relaxation,  and  by  taking  advantage  of  the  act  of  expiration,  the 
bulk  of  the  organ  may  be  appreciated  in  a  thin  person,  even  when  not 
greatly  increased.  Sometimes  in  children  the  healthy  kidneys  may  be 
felt  by  this  means  ;  but  as  a  rule  a  pali)able  kidney  is  a  diseased  kidney, 
more  especially  when  only  on  one  side.     In  three  cases  recently  under 

'  Lancet,  March  18tli,  1865. 

^  See  Prep,  in  St.  George's  Hospital  Museum,  Series  xi.  Prep.  38. 
^  "  Lectures  on  Extra-pelvic  Tumors  of  tlie  Abdomen,"  Brit.  Med.  Journ.  1869 
(Jan.  16th),  p.  43. 


40 


GENERAL  RELATIONS  OF  RENAL  TUMORS. 


my  care  a  comparatively  small  alteration  in  the  size  or  prominence  of 
one  kidney  was  appreciated  by  touch  during  life,  and  the  observation  sub- 
sequently verified.  In  one  tlie  organ  was  lifted  by  a  spinal  abscess  behind 
it ;  in  anotlier  it  was  stretched,  but  not  excessively,  as  the  result  of  an 
urethral  obstruction  ;  in  the  third  it  was  surrounded  by  adhesions  and 
increased  in  rotundity,  though  not  in  absolute  bulk,  as  consequences  of 
tubercular  disease.  Renal  tumors  are  indeed  often  appreciable  by  touch 
which  are  not  to  be  detected  by  any  other  means. 

As  such  tumors  increase  tliey  aiDproach  the  front  wall  of  the  abdo- 
men, usually  at  about  the  level  of  the  umbilicus,  perhaps  a  couple  of 
inches  on  one  side.  The  "presentation  "  of  a  renal  tumor  is,  liowever, 
various.  With  enlargement  it  fills  up  the  lateral  space  between  the  edge 
of  the  thorax  and  the  spine  of  the  ilium,  and  causes  that  region  to  impart 
a  sense  of  fulness  or  resistance,  and  in  some  cases  to  bulge,  to  the  loss  of 
bilateral  symmetry.  The  fulness  passes  towards  the  backbone,  and  is  to 
be  traced  as  far  as  the  great  lumbar  muscles  will  allow.  No  interval, 
either  of  increased  resonance  or  diminished  resistance,  is  to  be  made  out 
between  these  muscles  and  tlie  renal  mass:  important  as  a  means  of  dis- 
tinguishing renal  from  splenic  tumors.  AYlien  of  large  size,  renal  tumors 
may  bulge  laterally,  but  they  seldom  do  so  posteriorly,  their  presence 
being  indicated  here  rather  by  the  effacement  of  hollows — ''levelling 
up."  It  has  been  laid  down  that  such  tumors  never  protrude  posteri- 
orly, but  the  rule  is  not  without  exception.  A  pulsating  renal  growth  in 
St.  George's  Hospital  declared  itself  by  a  swelling  over  the  right  side  of 
the  sacrum." 

Renal  tumors,  whether  solid  growths  or  fluid  accumulations,  are  apt 
to  retain  much  of  the  original  shape  of  the  organ — sometimes,  indeed, 
almost  its  exact  shape — notwithstanding  great  increase  of  size.  There 
are,  of  course,  exceptions  to  this  rule,  where  growths  are  not  distributed 
through  the  gland,  but  sprout  from  a  single  spot,  as  from  a  part  of  the 
pelvic  areolar  tissue.  But  there  are  few  exceptions  to  the  rule  that  the 
kidney,  normally  rounded  as  it  is  in  every  direction,  never  acquires  a 
sharp  edge.  The  kidney  "is  rounded,"  says  Jenner,  "on  every  side, 
and  in  disease  never  loses  this  peculiarity."  This  point  may  often  be 
sufficient  to  determine  the  distinction  between  a  renal  enlargement  and 
one  belonging  on  the  one  side  to  the  liver,  or  on  the  other  to  the 
spleen. 

Xo  certain  inference  is  to  be  drawn  from  the  fact  that  a  tumor  de- 
scends with  inspiration.  Hepatic  and  splenic  growths  do  so;  the  latter 
conspicuously.  A  renal  growth  or  dilatation  is  commonly  fixed  posteri- 
orly, but  it  may  bend  upon  itself  so  that  its  fore  jiart  will  move  with  the 
diaphragm.  I  have  two  patients  at  the  present  time  with  pyelitis  and 
renal  dilatation;  in  both  the  upper  and  fore  part  of  the  mass  markedly 
descends  with  inspiration.  In  both  it  is  on  the  right  side,  so  that  it 
moves  with  the  liver,  though  distinctly  separable  at  least  from  its  ante- 
rior part. 

Tumors  of  the  kidney,  if  large,  may  compress  the  vena  cava,  and 
cause  as  much  exaggeration  of  the  superficial  abdominal  veins  as  is  pro- 
duced by  portal  obstruction;  this  appearance  is  therefore  of  little  diag- 
nostic significance. 

Urinary  changes  have  only  a  secondary  place  in  the  diagnosis  of  renal 
tumors.     Blood  or  pus  in  the  urine,  together  with  signs  of  renal  enlarge- 


'  Related  by  Mr.  T.  Holmes,  Path.  Trans,  vol.  xxiv.  p.  149. 


GENERAL  RELATIONS  OF  RENAL  TUMORS. 


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Abdominal  aspects  of  Renal  Tumors. 


'  Figs.  5  to  12  are  copied  from  Bright's  "  Abdominal  Tumors. 


42  GENERAL    KELATIONS    OF    RENAL    TUMORS. 

mcnt,  may  be  conclusive  as  to  the  nature  of  the  disease  ;  but  it  often 
happens  that,  if  the  enhirgement  be  solid,  the  growth  is  external  to  the 
]K'lvis,  and  exerts  no  aj)preciable  influence  upon  the  urine,  and  generally 
if  it  be  by  fluid  accumulation  that  the  exit  of  the  kidney  is  closed,  either 
permanently  or  with  only  occasional  escape,  so  tiiat  the  urine  which 
comes  under  examination  is  entirely  secreted  by  the  healthy  organ. 

It  may  be  of  use  to  epitomize  the  distinctions  by  which  tumors  of  the 
kidney  may  be  distinguished  from  each  of  the  forms  of  swelling  with 
which  they  are  liable  to  be  confused. 

First  as  to  the  liver.  Tumors  of  this  organ  are  continuous  down- 
Avardis  from  the  hypochondrium,  while  those  of  the  kidney  are  usually 
separated  by  softness  or  resonance  from  the  hepatic  position.  With  en- 
largements of  the  liver  an  acute  margin  can  generally  be  traced.  It  is 
only  in  exceptional  circumstances  that  bowel  is  to  be  discerned  before  an 
enlarged  liver. 

Splenic  swelling,  when  so  small  as  to  be  just  within  touch,  may  be 
behind  tiie  bowels,  and  so  far  like  one  of  renal  origin  ;  but  it  will  be 
traceable  upwards  to  beneath  the  ribs  as  a  renal  tumor  of  that  size  would 
not  be.  A  si)lenic  tumor  of  considerable  size  is  easily  distinguishable  by 
the  absence  of  bowel  in  front,  by  its  sharp  outline,  its  notch,  and  by  the 
existence  of  resonance  or  softness  between  itself  and  the  spinal  region. 
Further,  a  splenic  tumor  is  movable  ;  though  a  displaced  healthy  kidney 
may  move  freely,  an  enlarged  and  diseased  kidney  is  usually  fixed. 
Finally,  unilateral  bulging  may  suggest  that  the  cause  is  not  splenic  but 
is  connected  either  with  the  kidney  or  with  some  other  extra-peritoneal 
structure. 

The  distinction  between  renal  and  ovarian  tumors  is  of  large  practical 
importance.  The  position  of  the  bowels  is  the  chief  guide.  Renal  tu- 
mors almost  invariably  have  intestine  in  front  ;  ovarian  tumors  as  a  rule 
do  not.  Ovarian  tumors  as  a  rule  push  the  intestines  aside  as  they  come 
forward  and  abut  Avithout  interception  against  the  abdominal  wall.  This 
rule  is  unfortunately  not  quite  without  exception,  as  coils  of  bowel  have 
occasionally  become  fixed  by  adhesions  to  the  front  of  an  ovarian  tumor, 
.•ind  have  even  been  perforated  in  this  situation  by  a  trocar.  Thus  the 
presence  of  bowel  in  front  does  not  absolutely  disprove  the  ovarian  origin 
of  an  abdominal  tumor,  any  more  than  its  absence  absolutely  disproves 
its  renal  source  ;  but  the  indication  thence  derived  is  of  general  value. 
To  determine  the  absence  of  bowel  the  absence  of  resonance  is  notenough; 
the  rolling  of  empty  bowel  must  be  sought  for  by  slipping  the  integument 
with  the  fingers  ;  and,  if  necessary,  the  bowel  may  be  inflated  per  anum 
■ — a  measure  of  the  more  effect  as  the  intestine  to  be  expected  is  colon. 
Ovarian  tumors  are  usually  more  globular  than  renal,  and  more  central. 
Further,  a  distinction  may  be  made  by  vaginal  examination  :  if  the 
tumor  be  felt  within  the  pelvis  it  is  probably  not  renal,  nor  is  it  if  the 
uterus  be  much  lifted.  A  large  renal  tumor  depresses  the  uterus.  Fur- 
ther difference  may  be  found  in  the  fact  that  ovarian  cysts  are  often 
multilocular  ;  renal  cysts  of  such  size  as  to  be  prominent  as  abdominal  tu- 
mors are  generally  unilocular,  except  they  be  hydatids,  produced  as  they 
-are  by  simple  exaggeration  of  the  normal  cavityof  the  kidney. 

Tlie  al)senceof  albumin  and  the  ]n-e£ence  of  urea  in  the  fluid  con- 
tained would  ])robably  be  conclusive  of  a  renal  cyst  whether  the  alterna- 
tive were  ovaiian  dropsy  or  ascites.  "With  regard  to  the  latter  condition, 
in  Dr.  Hillier's  case,  where  for  a  time  hytlronephrosis  was  thus  inter- 
preted, the  diagnosis  was  finally  limited  to  that  of  renal  cyst  by  the  nature 


GENERAL  KELATIONS  OF  RENAL  TUMORS.  43 

of  the  fluid  withdrawn  :  this  was  essentially  urine,  it  contained  at  one 
time  no  albumin,  but  urea  and  uric  acid.  Other  points  of  distinction  be- 
tween ascites  and  hj'dronephrosis  may  be  found  in  those  of  ordinary  ap- 
plication in  the  distinction  of  encysted  and  peritoneal  dropsy,  and  in  the 
tracing  of  the  swelling  of  hydronephrosis  into  one  lumbar  region  with 
greater  bulging  on  that  side  than  on  the  other. 

As  to  the  supra-renal  bodies,  it  would  seem  strange  that  growths  here 
arising  should  be  distinguishably  differelit  in  their  relations  from  those  of 
the  kidneys  with  which  they  are  in  contact;  but  these  bodies,  though 
placed  behind  the  large  bowel,  are  not  overlaid  by  it  in  the  same  direct 
manner  as  are  the  kidneys,  and  though  I  have  but  a  single  case  to  appeal 
to,  yet  it  enables  me  to  say  at  least  that  supra-renal  tumors  are  not 
necessarily  crossed  by  bowel  as  renal  tumors  almost  invariably  are.  Tiie 
only  instance  I  know,  in  which  a  supra-renal  had  attained  sufficient 
dimensions  to  present  itself  during  life  as  an  abdominal  tumor,  occurred 
in  St.  George's  Hospital,  when  I  had  charge  of  the  post-mortem  depart- 
ment. A  girl  three  years  of  age  presented  in  the  right  hypochrondriac 
region  a  hard,  round,  slightly  movable  mass,  of  which  the  whole  circum- 
ference could  be  traced.  The  skin  was  generally  hypersemic  ;  it  was  gypsy- 
colored,  though  not  bronzed,  and  was  covered  with  a  remarkable  growth 
of  dark  hair.  The  tumor  proved  to  be  a  globular  mass  of  enceplialoid, 
six  inches  in  diameter,  which  had  replaced  the  left  supra-renal  capsule. 
This  lay  immediately  beneath  the  abdominal  wall,  uncovered  by  bowel  of 
4iny  kind.  It  had  pushed  itself  out  of  its  proper  place  in  regard  to  the 
kidney,  and  lay  along  its  inner  edge  close  to  the  hilum,  which,  with  the 
tumor  upon  it,  was  turned  forward,  the  growth  extending  without  inter- 
ruption between  the  concave  margin  of  the  kidney  and  abdominal  front. 
Thus  the  tumor  had  assumed  the  position  but  not  the  relations  of  a  renal 
enlargement.' 

Tumors  which  spring  from  some  of  the  absorbent  glands,  whether 
lumbar  or  mesenteric,  in  the  immediate  neighborhood  of  the  kidney,  may 
be  indistinguishable  from  those  belonging  to  that  organ.  The  annexed 
outlines  refer  to  a  case  of  encephaloid  disease  of  the  lumbar  glands  which 
had  most  of  the  renal  characters.  The  mass,  part  of  which  was  the 
healthy  kidney  and  part  a  mass  of  cancer  which  had  started  in  the  lum- 
bar glands,  was  crossed  by  the  descending  colon  nearly  in  the  position  of 
the  line  in  the  second  diagram  which  limits  the  palpation  area.  As  is 
apt  to  occur  with  renal  cancer,  the  lumbar  vertebras  had  been  invaded 
and  paraplegia  produced.  In  this  case  it  was  believed  until  death  that 
the  tumor  was  renal,  and  it  is  not  easy,  even  in  the  light  of  i\\Q  post- 
mortem, to  see  how  a  distinction  could  have  been  made. 

In  another  case,  also  of  a  child,  1  met  with  more  success.  The  tumor, 
like  the  preceding,  belonged  to  the  lumbar  glands  ;  in  position  and  rela- 
tion it  was  not  to  be  distinguished  from  a  renal  tumor,  save  that  a  pro- 
trusion from  it  entered  the  scrotum,  a  circumstance  which  suggested  its 
origin  in  the  lumbar  region  in  relation,  not  with  the  kidney,  but  with 
the  testicle.  A  character  which  helped  to  guide  the  diagnosis  in  this 
case,  and  of  which  I  have  seen  the  value  in  others,  is  the  more  marked 
or  abrupt  prominence  of  the  swelling  than  is  usual  with  renal  tumors. 


'The child  was  under  the  care  of  Dr.  Pitman,  in  St.  George's  Hospital,  in  the 
year  1864.  The  post-mortem  examination  was  made  by  myself.  The  preparation 
IS  in  the  museum  of  the  hospital,  series  x.  prep.  51.  It  is  described  by  Dr.  John 
Ogle  in  \\\e  Path.  Trans,  vol.  xvi.  p.  250. 


44 


GENERAL   RELATIONS    OF   RENAL    TUMORS. 


The  growth  consisted  of  fibroid  and  adenoid  tissue,  together  with 
many  cystiform  cavities. 


Encephaloid    of   lumbar  glands  simulating 
a  renal  tumor,  as  it  appeared  in  March. 


Same  tumor,  as  it  appeared  in  the  following 
August.  Shading  =  palpable  tumor.  Outer 
line  —  dulness. 


In  a  third  instance  within  my  own  experience,  of  a  glandular  simu- 
lating a  renal  tumor,  its  origin  was  in  one  of  the  mesenteric  glands/ 


Adenoid  cystic  tumor  of  lumbar  glands,  which  descended  into  scrotum,  but  otherwise  simu- 
lated a  renal  tumor,  as  seen  during  life.  The  cysts  are  full  and  tense.  The  dotted  line  shows  the 
extent  of  dulness.    (See  woodcut  on  next  page.) 

'  The  accompanying  cases  of  glandular  simulating  renal  tumors  are  fully  de- 
tailed in  the  Path.  Trans,  vols.  xxi.  and  xxii.  The  woodcuts  are  reproduced 
from  these  volumes. 


GENERAL  RELATIONS  OF  RENAL  TUMORS. 


45 


The  relations  of  the  tumor,  as  made  out  during  life  and  displayed  after 
death,   are   represented  in    the    outlines  on    this  page.      The    subject 


Tumor,  outlined  from  life  on  last  page,  as  dis- 
played after  death,  and  after  removal  of  the 
small  bowel.  The  cysts  are  somewhat  collapsed. 
The  scrotal  prolongation  is  seen. 


Mesenteric  simulating  a  renal  tumor  as  seen 
during  life.  The  shaded  portions  were  eoverea 
by  bowel,  two  coils  of  \vhich  could  be  traced  m 
front  of  the  tumor.    (See  woodcut  below.) 


mor  was  iSlcose^,  one  layer  pas.sing  upwards,  the  other  downwards  over  it. 


46 


GENERAL    RELATIONS    OF    RENAL    TUMORS. 


WHS  a  child  two  years  of  age;  the  tumor  was  highly  compound  in  its 
nature,  containing  fibroid  tissue,  fat,  cartilage,  bone,  and  muciform 
fluid. 

There  may  be  enough  resemblance  between  a  faecal  mass  in  the  as- 
cending or  descending  colon  and  a  renal  tumor  to  make  it  needful  to 
state  the  distinctions.  A  floating  kidney,  which  may  lie  under  the  pari- 
etes  entirely  uncovered  by  bowel,  may  so  nearly  resemble  a  faecal 
accumulation  as  to  be  not  at  once  distinguishable  from  it.  Both  are 
readily  movable  under  the  hand,  and  both  give  on  percussion  about  the 
same  amount  of  dulness,  not  profound,  but  that  of  a  superficial  mass 
lying  upon  the  intestines.  But  a  floating  kidney  is  a  rare  condition, 
more  often  suspected  during  life  than  found  after  death.  To  recognize 
it  with  anything  like  certainty,  not  only  should  the  shape  and  size  be  pro- 
perly renal,  but  the  hilum  should  be  felt.  What  doubts  remain  may 
be  solved  by  the  action  of  purgatives.  Not  that  an  accumulation  must  at 
once  disappear,  though  under  treatment  it  will  gradually  lose  bulk  and 
eventually  do  so.  The  resemblance  between  a  faecal  mass  and  a  floating 
kidney  does  not  hold  in  the  ordinary  conditions  of  renal  disease,  the  deep 
connections  of  a  renal  enlargement  and  the  existence  of  bowel  before  it 
being  enough  to  exclude  any  such  question. 


CHAPTER    VI. 

PATHOLOGY   AND   VARIETIES   OF   RENAL  TUMORS. 

REifAL  tumors  may  be  solid  growths,  or  distentions  by  liquid,  or  a 
mixture  of  both. 

Tliey  may  be  conveniently  arranged  as  follows: 

1.  Cancer  or  carcinoma.  Comprising  the  subdivisions  encephaloid, 
scirrhus,  and  colloid. 

2.  Sarcoma.     Mostly  of  a  higlily  malignant  character. 

3.  Fibro-fatty  tumor,  a  variety  of  sarcoma. 

4.  Fibroma. 

5.  Melanosis,  often  complicated  with  otlier  growths. 

6.  Villous  tumor.  Associated  with  one  of  the  former  growths,  but 
conveniently  classed  separately. 

7.  Lympluidenoma. 

8.  Tubercle. 

9.  Leuk^emic  tumor. 

10.  Angioma. 

11.  Syphiloma. 

12.  Lipoma,  fatty  tumor,  or  replacement. 

13.  Bony  or  calcareous  formations. 

14.  Cystic  disease. 

15.  Hydatids^ 

16.  Dilatations  of  the  pelvis — hydronephrosis,  pyonephrosis. 

The  purpose  of  the  present  chapter  is  to  deal  with  growths,  exclusive 
of  tubercle,  which  is  considered  separately. 

Distribution  of  Malignant  Renal  Growths. 

A  few  statements  will  apply  to  malignant  tumors  of  the  kidney  in  gen- 
eral, irrespective  of  any  distinction  between  cancer  and  sarcoma — such  a 
distinction,  indeed,  is  a  refinement  of  modern  pathology;  it  is  seldom  to 
be  established  during  life,  and  even  after  death  is  not  evident,  save  to 
modes  of  examination  which  are  not  commonly  employed. 

Renal  malignant  growths  may  be  practically  divided  into  primary  and 
secondary,  forming  two  class  of  very  unequal  importance.  When  pri- 
mary, the  growth  usually  affects  one  kidney  only,  and  destroys  life  by  its 
progress  in  or  about  the  organ  in  which  it  has  originated.  Secondary 
renal  growths  are  continually  bilateral;  they  usually  escape  notice  during 
life,  playing  quite  a  subservient  part  to  that  in  which  they  have  origi- 
nated. The  secondary  are  the  more  common;  speaking  indeed  of  cancer 
as  distinguished  from  sarcoma,  this  growth  is  exceedingly  rare  in  the 
kidney,  excepting  as  having  originated  elsewhere;  tumors  primary  to  the 
kidney  are  more  often  sarcomatous. 

I  have  collected  from  the  records  of  the  hospitals  with  which  I  am 


4S 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TUMORS. 


tissociated,  together  with  m}'  individual  experience,  the  notes  of  seven- 
teen cases  of  malignant  tumor  primary  to  the  kidney,  and  of  twenty- 
three  secondary  to  it.  As  they  are  for  the  most  part  unpublished,  they 
form  an  addition,  however  trifling,  to  current  knowledge. 

To  take  first  the  class  which,  though  the  smaller,  has  the  larger 
practical  importance — malignant  renal  growths  belong  to  two  periods  of 
life,  early  childhood  and  declining  age;  in  late  childhood  and  early  adult 
life  tliey  are  nearly  unknown,  at  least  as  original  to  the  kidney.  The 
following  table  gives  the  particulars  of  distribution: 


Age  at  death. 


Malignant  growths  primary  to 
the  kidney,  17  cases 

Malignant  growths  secondary 
to  the  kidney,  23  cases 


0  to 

6  to 

11  to 

21  to 

31  to 

5 

10 

20 

30 

40 

yrs. 

yrs. 

yrs. 

yrs. 

yrs. 

6 

1 

3 

1 

2 

4 

3 

41  to 

50 

yrs. 


51  to 

60 
yrs. 

61  to 

TO 

yrs. 

2 

4 

3 

Over 

70 
yrs. 


Primary, 
Secondary, 


Male,    9,  female,  8. 

"      15,       •'        8. 


The  proportion  of  children  affected  is  slightly  greater  than  would 
generally  present  itself,  as  the  table  includes  the  experience  of  the  Hos- 
pital for  Sick  Children,  from  which  source  two  of  the  cases  of  primary 
and  one  of  secondary  growth  were  derived.  The  j)Ost-morte7n  examina- 
tions at  this  hospital  from  its  foundation  to  March,  1878,  are  1,084  in 
•number.  These  comprise,  besides  the  cases  of  renal  growths  just  referred 
to,  eleven  of  so-called  cancer  beginning  in  other  organs;  but  the  disease 
had  not  originated  in  any  organ  in  more  than  one  instance,  excepting 
the  skeleton  and  the  peritoneum — each  of  which  were  primarily  affected 
in  two  cases — and  the  kidney.  The  frequency  of  malignant  renal 
growths  in  childhood  may  be  associated  with  the  fact  that  these  tumors 
are  generally  of  the  nature  of  sarcoma,  and  belong,  like  the  tumors  of 
the  eyeball,  not  infrequent  at  the  same  time  of  life,  to  the  connective  tis- 
sue. Tumors  which  originate  in  this  tissue,  whether  as  glioma  or  sar- 
coma, appear  to  be  more  common  in  early  life  than  the  strictly  cancerous 
growths  which  take  their  rise  in  the  epithelium. 

Whatever  be  the  intimate  structure  of  renal  growths,  they  present  in 
a  large  majority  of  instances  the  outward  semblance  of  encephaloid. 
Like  most  new  formations  they  are  most  luxuriant  in  childhood  and  pre- 
sent at  this  time  of  life  the  softest  structure,  and  relatively,  or  even  ab- 
solutely, the  largest  bulk.  Sometimes  the  dimensions  have  been  enor- 
mous. Spencer  Wells^  saw  one  in  a  child  four  years  old  which  weighed 
between  sixteen  and  seventeen  pounds,  and  had  grown  so  rapidly  that 
hardly  six  months  had  elapsed  from  its  appearance  to  its  termination. 
An  outline  of  the  swelling  is  given  at  page  41,  in  juxtaposition  to 
which  is  to  be  seen  a  similar  outline  from  a  bov  of  six  who  was  the  sub- 


'  Of  the  forty  cases  here  referred  to,  thirty-seven  were  descril^ed  as  encepha- 
loi<l.  two  as  scirrhus,  one  as  colloid;  but  these  distinctions  had  reference  to  little 
more  than  the  consi.stence  of  the  tumor,  and  are  not  to  be  accepted  in  reference 
to  the  minute  structure. 

»  Duhl.  Quart.  Journ.,  1867.  p.  126. 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TUMORS.  49 

ject  of  a  renal  tumor'  described  as  enceplialoid,  which  weighed  thirtv- 
one  pounds,  the  total  weight  of  the  child  and  tumor  together  having 
been  131  pounds,  so  that  about  a  fourth  of  the  creature  was  disease.  A 
child  of  three  years  old,  named  Lily  Langley,  died  under  my  care  at  the 
Hospital  for  Sick  Children  with  a  renal  sarcoma;  the  body  unopened 
weighed  thirty-five  pounds,  the  tumor  eleven  and  a  half  pounds,  almost 
exactly  a  third  of  the  whole. 

The  instance  of  a  child  three  years  old  has  already  been  referred  to, 
in  whom  a  renal  sarcoma  was  mistaken  during  life  for  ascites,  such  were 
its  dimensions  and  consistence.  Dr.  Eoberts  found  that  the  average 
Aveight  of  the  renal  tumor  in  sixteen  children  whose  cases  he  had  col- 
lected amounted  to  eight  and  a  half  pounds;  the  smallest  weighed  one 
pound  nine  ounces.  Among  fifteen  adults  the  average  weight  was  nine 
and  a  half  pounds,  the  growth  in  the  smallest  presenting  about  the  size 
and  weight  of  the  natural  kidney.  Notwithstanding  the  large  variations 
of  size  which  renal  tumors  present,  it  may  be  stated,  as  a  rule  whicli  has 
few  exceptions,  that  a  renal  growth,  though  it  may  not  protrude  the 
^ibdominal  surface,  seldom  fails  to  attain  such  a  size  as  to  be  evident  to 
the  touch,  though  the  nature  of  the  enlargement  has  in  many  cases  been 
misunderstood. 

Growths  primary  to  the  kidney  usually  belong  especially  to  one.  It 
is  not  the  habit  of  any  malignant  growth,  whether  cancer  or  sarcoma,  to 
start  bilaterally,  as  do  morbid  actions  which  depend  upon  the  blood  or 
the  nervous  system,  and  the  general  truth  that  however  widely  such 
growths  may  be  scattered,  one  is  generally  to  be  recognized  as  the  pro- 
genitor of  all  the  rest,  makes  one  suspicious  of  the  double  origin 
which,  as  far  as  the  kidneys  are  concerned,  is  sometimes  assigned  to 
them.  Among  the  nineteen  cases  of  malignant  disease  primary  to  the 
kidney  referred  to  at  page  50  were  four  in  which  both  organs  partici- 
pated. 

In  two,  many  secondary  deposits  existed  elsewhere,  so  that  one  of  the 
renal  growths  was  probably  of  this  nature.  In  the  other  two,  growths 
Avere  found  in  the  two  kidneys  and  nowhere  else,  so  that  independence 
of  origin  might  be  inferred;  but  in  each  instance  the  growths  were 
greatly  unequal  in  size,  so  that,  to  say  the  least,  they  were  not  simulta- 
neous, and  it  is  not  impossible  that  the  second  may  in  each  case  have 
l)eon  the  offspring  of  the  first,  though  none  elsewhere  came  under  obser- 
vation. 

Among  sixty-seven  cases  of  primary  renal  so-called  cancer  collected 
by  Roberts,  the  disease  was  confined  to  one  kidney  sixty  times.  In  seven 
■cases  both  were  involved,  but  in  three  only  did  the  disease  appear  to  be 
primary  on  both  sides;  in  the  other  four  one  kidney  was  the  seat  of 
]irimary  cancer,  while  its  fellow  contained  only  secondary  nodules. 
Other  writers,  like  Dr.  Roberts,  have  collated  published  cases  with  simi- 
lar results,  but  to  quote  any  other  statement  from  similar  sources  would 
be  but  to  count  the  same  cases  twice. 

With  regard  to  the  lateral  selection  of  renal  growths  the  testimony  is 
somewhat  discrepant.  Roberts  found  that  of  sixty  unilateral  cases  each 
kidney  was  affected  an  equal  number  of  times.  Ebstein  states  that  the 
right  is  more  often    attacked  than   the  left  in  the  ratio  of  31   to  23. 


'  Under  the  care  of  the  late  Dr.  Hawkins  in  tiie  Middlesex  Hospital.  Reported 
by  Dr.  Van  de  Bvl,  Path.  Trans,  vol.  vii. 
4 


50  PATHOLOGY    AND     VARIETIES    OF    RENAL    TUMORS. 

Among  my  cases,   putting   aside  four  Avhicli  affect  both   kidneys,  are 
eleven  belonging  to  the  left  side,  only  one  belonging  to  the  right. 

Looking  at  the  position  of  malignant  tumors  with  regard  to  the  kid- 
ney itself,  it  is  ai)purent  that  there  are  two  situations  in  which  they 
chiefly  begin — the  coitical  structure  and  the  submucous  cellular  tissue. 
Cancers  certainly  begin  as  a  rule  in  the  cortex,  but  cases  present  them- 
selves in  which  the  growtli  is  placed  chiefly  in  the  interval  between  the 
gland  and  the  pelvis.  This  may  be  only  because  the  growth  has  pushed 
in  this  direction,  as  in  an  instance  under  my  own  observation,  where  a 
tumor,  regarded  as  encephaloid,  largely  occupied  this  position  and  pro- 
truded thence  into  the  mucous  cavity;  but  that  it  had  begun  in  the 
I'enal  substance  was  proved  by  the  circumstance  that  the  protruding  part 
displayed  upon  its  surface  the  divergent  lines  of  a  niammillary  process, 
so  that  the  growth  had  evidently  begun  behind  this  structure  and  pushed 
it  before  it. 

But,  beside  such  cases  in  which  the  cellular  interspace  is  the  apparent 
rather  than  the  real  source  of  the  growth,  others  have  been  describeil, 
and  the  term  imranepliric  applied  to  them,  in  which  the  actual  origin 
of  the  cancer  is  liere,  and  its  subsequent  progress  directed  not  into  the 
substance  of  the  organ,  but  around  it  in  connection  with  the  capsule.' 
I  have  recently  had  a  case  of  an  abdominal  tumor  which  was  regarded, 
correctly  as  it  proved,  as  a  renal  sarcoma.  The  growth,  however, 
though  in  the  closest  contact  witii  the  glandular  surface,  was  distinct 
from  its  substance,  tlie  gland  being  expanded  into  a  shell  over  the  tumor. 
No  transition  of  gland  into  growth  could  be  traced;  and  it  was  not  pos- 
sible but  to  conclude  that  the  tumor  had  arisen  between  the  kidney  and 
its  mucous  or  fibrous  covering.  Wliether  such  growth  arise,  as  has  been 
supposed,  in  the  endothelium  of  the  blood-vessels  I  am  unable  to  say. 
As  to  secondary  cancerous  growths,  they  are  often  seen  around  blooa- 
vessels,  as  if  brought  by  them  or  by  the  accompanying  lymphatics;  thus 
they  may  be  placed  in  the  cellular  interspace  of  the  kidney,  just  as  simi- 
lar formations  may  appear  between  gland  and  vessel  in  the  portal  canals 
of  the  liver. 

The  malignant  sarcomata  are  often  so  intimately  associated  with  the 
interstitial  tissue  of  the  cortex  involving  the  tubes  within  their  encroach- 
ing bulk  and  spreading  around  the  Malpighian  bodies,  that  it  must  be 
inferred  that  the  growth  has  begun  in  that  tissue  with  the  distribution  of 
which  its  spread  is  so  intimately  connected;  thus  sarcomata  as  well  as 
cancer  would  seem  to  be  mainly  of  cortical  origin.  But  either  may 
spread  in  the  submucous  interval;  and  the  position  of  secondary  growths 
of  either  sort  may  be  determined,  as  already  stated,  by  that  of  the  blood- 
vessels and  absorbents  in  this  situation.  Lymphadenomata  sometimes 
especially  belong  here,  accurately  following  the  submucous  interval  and 
dissecting  the  membrane  from  the  dand. 


Distribution   of  Growths  Secondary  to  those  in  the   Kidney. 

Secondary  growths  in  nineteen  cases  of  malignant  tumor  primary  to 
the  kidney,  from  St.  George's  and  the  Hospital  for  Sick  Children,  and 
private  notes. 


Zenker  and  Schroder,  quoted  by  Ebstein,  Ziem.  Cycl.  vol.  xv.  p.  668. 


PATHOLOGY    AND    VARIETIPrS    OF    KENAL    TUMORS.  51 

Cases 
No  growth  recorded  except  in  one  kidney,         ....        3 
Both  kidneys  affected,  no  growth  elsewhere,     ....        2 
Both  kidneys  affected,  one  perhaps  secondarily  as  other  secondary 

growths  existed,  .......        2 

["Secondary  gi'owths  in  lumbar  glnnds,  .  .        9 

I  In  mesenteric,  omental,  mediastinal,    or    cervical 
Conveyance     |  glands,  ......        5 

by  absorbents  |  In  lungs  and  pleurae,      .  .  .  .  .6 

and  j  In  liver,  ......         4 

blood-vessels.  I  In  peritoneum,  .....        1 

I  In  uterus,  .  .  .  .  .  .1 

[^  In  interior  of  craninum  (?),       .  .  .  .1 

f  Involving  supra-renal  body,      ....  3 

Extension  by  j  Vertebrae,  ......  .3 

contiguity,     j  Spinal  cord,  ......  2 

(Bowel,       .......  1 

The  influence  of  a  malignant  renal  growth  upon  neighboring  and  re- 
lated structures  is  of  more  than  pathological  interest.     Like  other  malig- 
nant tumors  it  not  only  travels  along  the  lines  of  lymphatic  and  venous 
departure,  but  spreads  by  contiguity.     It  frequently  encroaches  upon  the 
renal  vein,  and  has  been  known  to  thrust  itself  in  bulk  into  it  and  into  the 
associated  vena  cava,  and  to  reach  the  lung  in  the  shape  of  palpable 
emboli.     As  a  rule  it  appears  to  start  by  the  absorbents  ;  the  lumbar 
glands,  receiving  as  they  do  the  lymphatics  from  the  kidney,  are  usually 
infiltrated  as  the  first  step  in  the  advancement  of  the  disease  :  they  may 
thus  become  converted  into  a  cylinder,  or  irregular  mass  of  malignant 
growth,  which  lies  immediately  in  front  of  the  spine,  and  in  which  the 
aorta  and  vena  cava  are  completely  imbedded.     After  the  lumbar  glands, 
tlie  infection  is  next  potired  into  the  thoracic  duct  and  venous  blood, 
and  reaches  the  lung  as  presenting  the  first  capillaries  to  be  traversed 
after  the  infection  has  been  discharged  by  the  lumbar  glands  and  entered 
the  blood.     After  leaving  the  lung  and  reaching  the  left  ventricle  the 
infection  is  necessarily  impartially  distributed — sown  broadcast  through 
the  system  to  bear  fruit  in  whatever  structure  is  suited  to  arrest  the  con- 
tagium  and  lend  itself  to  its  development.     The  liver  and  the  general 
absorbent  glands  appear  to  be  affected  most  often  ;  the  bones,  tlie  peri- 
toneum, and  the  heart  occasionally,  but  with  less  frequency.     My  series 
does  not  include  an  instance  in  svhich  the  heart  Avas  affected,  but  there 
are  three  in  a  list  of  fifty-one  cases  of   primarily  renal   "cancer"   (for 
cancer  read  malignant  growth)  collected,  mostly  from  published  reports, 
by  Dr.  Eoberts.     In  the  same  collection  the  bladder,  uteru-,  penis,  and 
testicle  were  each  in  one  instance  the  subject  of  secondary  deposits.     But 
besides  its  distribution,  as  in  these  instances,  by  absorption  and  dissemi- 
nation, it  has  other  and  more  arbitrary  modes  of  i)rogression.     It  may 
liappen  that  its  most  fatal  and  distressing  issues  are  due  to  its  annexation 
of  organs  and  structures  which   have  no  association  with  it  but  one  of 
vicinity.     The  most  important  result  of  this  kind  is  the  implication  of 
the  spinal  column  and  cord.     It  has  happened  to  me  to  witness  two  in- 
stances of  thi§  :  in  one,  the  kidney  was  the  seat  of  a  malignant  sarcoma; 
the  vertebras  affected  were  the  last  three  dorsal,  and  the  first  lumbar:  the 
body  of  the  last  dorsal  was  so  extensively  destroyed  that  when  the  spinal 
canal  was  laid  open  after  death,  the  finger  could  be  passed  through  a  jagged 
hole  from  the  spinal  into  the  abdominal  cavity.     The  resulting  paraplegia, 


52  PATHOLOGY    AND    VAKIKTIES    OF    REXAL    TUMORS. 

Avitli  ])ar;ilysis  of  the  bladder  and  deep  bedsores,  liad  been  as  complete  as  if 
the  spine  had  been  broken  by  external  violence.  In  the  other  case,  that  of  a 
man  named  Temi)ero,  precisely  the  same  vertebras,  the  last  three  dorsal 
and  the  first  lumbar,  had  been  similarly  involved  from  the  same  cause  ; 
and  one,  tlie  eleventh  dorsal,  had  been  completely  cut  in  two,  so  that  the 
upper  segment,  during  life,  grated  upon  the  lower  with  the  distinguisii- 
ing  crepitus  of  broken  bone — a  ])henomenon  Avhich  was  to  be  elicited  by 
slight  pressure  upon  the  spinous  process  of  the  affected  vertebra.  In 
this  case,  althougii  much  cancerous  matter  was  found  in  the  spinal  (?anal, 
there  was  no  i)aralysis  but  of  the  l)ladder.  The  bowel  also  suffers  from 
its  proximity  to  the  renal  growth:  an  instance  has  been  mentioned  in 
which  the  descending  colon,  and  another  in  which  the  duodenum  was 
perforated.  The  latter  bowel  has  been  often  completely  imbedded  in  a 
malignant  mass  of  renal  origin,  as  in  a  subject  examined  at  St.  George's 
Hospital ;  and  dilatation  of  the  stomach  has  been  known  to  have  resulted 
from  compression  of  the  duodenum  by  the  same  means. 

The  aorta  and  vena  cava  may  be  in  like  manner  nearly  surrounded, 
insomuch  that  it  is  a  matter  of  surprise  that  the  vessels  themselves  escape 
destruction  ;  they,  however,  though  possibly  compressed,  preserve  their 
integrity  in  a  manner  which  shows  them  to  be  exceptionally  resistant  to 
encroaching  growths. 

The  fre(juency  with  which  the  supra-renal  capsule  participates  in 
renal  cancer  is  no  doubt  due  to  its  apposition  rather  than  its  suscepti- 
bility. It  has  often  been  noticed  that  a  growth  primary  to  the  kidney 
rarely  extends  to  tlie  other  urinary  or  genital  organs:  while  it  is  by  no 
means  uncommon  for  cancer  of  the  testicle  to  be  succeeded  by  cancer  of 
one  or  more  kidneys.  Transmission  of  the  disease  in  the  contrary  direc- 
tion is  exceptional.  The  reason  is  not  far  to  seek.  Malignant  disease  is 
conveyed  chiefly  by  the  absorbents  ;  those  of  the  kidney  pass  to  tlio 
lumbar  glands,  and  so  to  the  thoracic  duct,  their  course  lying  above,  and 
their  current  setting  away  from  the  pelvic  and  lower  organs.  These 
organs,  of  course,  share  in  common  with  every  other  in  whatever  systemic 
contamination  may  exist,  but  they  have  no  particular  or  special  associi- 
tion  with  the  morbid  process  beyond  the  exposure  of  the  urinary  mucous 
membrane  to  morbid  discharges.  But  more  often  than  not  the  growth 
is  not  exposed  m  the  renal  cavity,  nor  is  the  urine  affected  by  it;  and 
even  when  it  fungates  and  discharges  into  the  pelvis  the  discharge  ap- 
])ears  to  have  little  of  infective  property.  With  regard  to  the  conveyance 
of  disease  in  the  other  direction,  the  lymphatics  of  the  testicle  pass 
directly  into  the  lumbar  glands,  some  to  those  of  them  which  lie  near 
the  renal  artery;  if  these  become  infiltrated  the  kidney  may  easily  be 
affected  by  contiguity,  giving  place  as  it  does  to  growths  intruding  from 
without.  The  jirostate,  bladder,  and  uterus  are  likewise  connected  with 
the  lumbar  glands,  but  less  directly  tluin  is  the  testicle.  Cancer  of  the 
kidney  is  not  a  frequent  result  of  cancer  of  the  uterus:  it  has  been  traced 
to  cancer  of  the  prostate. 

Subdivisions  and  Minute  Anatomy  of  Eenal  G-rowths. 

Malignant  tumors  of  the  kidney  have  been  so  generally  described  as 
cancer,  that  it  was  with  much  surprise  tiiat  I  found,  on  examining  a 
number  of  specimens  to  which  this  name  had  been  applied,  that  cancer, 
as  structurally  defined,  was  comparatively  rare  among  them.  By  far  the 
larger  number  of  malignant  venal  growths  fall  within  the  definition  of 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TUMORS.  53 

sarcoma;  and  the  preponderance  of  tliis  form  of  growth  over  tlie  cancer- 
ons  becomes  still  more  marked  if  we  liave  regard  only  to  such  as  are 
primary  to  the  kidney.  Of  eiglit  tumors  catalogued  as  cancer  in  the 
Museum  of  St.  George's  Hospital,  two  of  which  were  specified  as  scirrliu.^, 
six  proved  to  be  not  cancer  but  sarcoma,  tlie  term  "scirrhus"  having 
been  applied  in  each  instance  to  a  hard  sarcomatous  growth.  Not  that 
this  is  the  only  growth  which  may  simulate  renal  cancer:  I  have  conio 
across  two  instances  in  which  a  formation  apparently  of  this  nature,  and 
secondary  to  ulcerating  cancer  elsewhere,  has  proved  to  be  notliing  more 
than  a  cell-infiltration,  inflamnuitory  in  nature,  and  probably  akin  to 
pyaemia. 

A  profusely  cellular,  highly  malignant,  round-celled  sarcoma  is  the 
most  common  of  all  renal  growths.  It  is  of  interest  to  note  that  uoh 
only  as  concerns  the  forms  of  albuminuria,  but  also  with  circumscribed 
morbid  growths,  the  most  frequent  seat  of  disease  is  the  intertubular  in- 
terval, and  the  growths  to  Avhich  the  organ  is  most  prone  are  exaggera- 
tions or  perversions  of  its  connective  tissue.  This  has  more  than  scho- 
lastic importance,  for  it  helps  to  explain  why  renal  tumors  so  seldom 
disturb  the  renal  function.  The  growths,  though  within  the  capsule, 
may  be  called  extra-glandular  ;  they  have  no  connection  with  the  secret- 
ing channels,  and  only  affect  the  secretion  when  by  accident  of  fungatiou 
the  products  of  their  ulceration  are  mixed  with  the  urine  in  the  pelvis. 
Clinically  it  is  but  seldom  possible  to  separate  cancer  from  sarcoma,  or 
to  distinguish  a  renal  tumor  during  life  more  narrowly  than  as  being 
either  one  or  the  other  :  a  clinical  sketch  must  be  common  to  the  tw(), 
but  to  this  must  be  superadded  a  word  about  the  pathological  characters 
proper  to  each.' 

Carcinoma. 

Cancers  of  the  kidney  are  usually  encephaloid  ;  scirrhus,  though  often 
spoken  of,  is,  in  fact,  exceedingly  uncommon  in  this  situation.  I  have 
ascertained  a  renal  tumor  to  be  strictly  of  this  nature  in  but  one  in- 
stance, for  the  opjiortunity  of  examining  which  I  am  indebted  to  my 
friend  Mr.  C.  H.  Morgan.     The  subject  was  a  man  of  the  age  of  sixtv- 

'  In  evidence  of  tlie  relative  frequency  of  carcinoma  and  sarcoma  as  renal 
growths,  I  may  mention  that  in  the  course  of  a  systematic  examination  of  renal 
tumors  by  means  of  translucent  sections,  I  found  six  instances  of  carcinoma  to 
sixteen  of  sarcoma.  The  carcinomas  comprised  one  case  of  colloid,  one  of  scir- 
rhus, and  four  of  encephaloid.  The  colloid  and  scirrhus  were  primary  to  the  kid- 
ney ;  one  of  the  encephaloid  was  primary,  two  secondary,  and  one  uncertain  ia 
this  respect.  Of  the  sarcomas,  nine  w-ere  primary  to  the  kidney,  six  secondary, 
one  uncertain.  As  to  the  structure  of  the  sarcomas,  fourteen  of  the  sixteen  were 
round-celled,  the  small-celled  variety  prevailing ;  two  were  spindle-celled. 
Among  the  round-celled  varieties  were  five  which  the  abundance  of  extra  vasated 
blood  entitled  to  be  called  haemorrhagic  ;  two  which  were  alveolar,  and  thus  ap- 
proached the  characters  of  cancer.  Alveolar  sarcoma  so  nearly  resembles  cancer 
that  it  is  with  difficulty  to  be  distinguished  from  it.  It  would  indeed  appear 
that  carcinoma  and  sarcoma  are  not  sei)arated  by  so  definite  a  line  as  modern 
pathology  would  indicate.  The  alveoli  of  a  sarcoma  may  so  nearly  i-esemble  can- 
cerous loculi  that  it  is  only  in  other  parts  that  the  distinction  is  clear  ;  and  even 
with  them  it  is  not  always  conclusive,  for  the  solid  portions  of  a  cancer  are  not 
always  to  be  distinguished  from  sarcomatous  tissue.  I  have  seen  at  least  one  in- 
stance of  a  renal  growth,  which  could  not  be  regarded  but  as  sarcoma,  which 
was  secondary  to  one  in  the  rectum,  which  had  been  pronounced  on  microscopic 
evidence  to  be  carcinoma.  Clinically  it  is  not  possible  to  distinguish  in  the  in- 
dividual case,  though  we  know  generally  that  in  one  organ  the  growth  is  likely 
to  be  sarcoma,  in  another  cancer.     As  to  malignancy  there  is  little  to  choose. 


54 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TUMORS. 


eio-ht ;  the  disease  ]n-imary  to  the  left  kidney  ;  the  cause  of  death  second- 
ary growths  of  the  same  nature  in  the  pleura,  with  consequent  serous 
effusion.  I  have  recently  examined  two  other  instances  of  su]i]iosed  scir- 
rhus  of  the  kidiiov,  and  found  both  to  be  sarcoma.  Colloid  of  the 
kidnev  is  :il.=o  infroqnent  ;  an  instance  will  shortly  I)e  referred  to  (]l  55). 
Two  modes  have  been  (lescril)od  in  which  renal  cancer  may  begin,  and 
the  distinction  may  ajjply  to  other  growths  also.  The  growth  may  be 
discrete  or  diffuse.  In  the  first  one  or  more  isolated  and  circumscribed 
formations  ajipear  in  the  cortical  tissue,  and  sometimes  project  from  it  in 
enormous  bulk,  leaving  some  portion  of  the  organ  unaffected,  except  by 
distortion  and  displacement.  In  the  other  form  the  growth  takes  place 
generally  throughout  the  organ,  or  mingles  intimately  with  it  from  many 
points,  so  that,  however  the  organ  increases  in  size,  it  retains  much  of 
its  original  sliape.  In  the  first  form  the  tumor  may  be  placed  far  away 
from  the  renal  ])elvis,  and  have  no  tendency  to  approach  it ;  and  indeed 

in  every  form  of  renal  can- 

i"'/-r^.'"jC-:-:-^>--'-'^-;/l 


'^S'0:.-r^ 


:i"Si-:!  \:*w^  ■.^<J>: :  -'jiV  *'■ 


%<J' 


'^<i 


vU 

"li#^" 


'■"^v^?: 


cer,  fungation  into  the  pel- 
vis and  the  admixture  of 
cancerous  discharges  with 
the  urine  is  an  exceptional 
event. 

To  add  the  results  of 
microscopic  examination, 
cncejihaloid  and  scirrhus, 
usually  beginning,  as  has 
been  seen,  in  the  cortex, 
there  jiresent  their  well- 
known  alveolar  structure. 
In  the  usual  form  each 
nodule  or  mass  is  limited 
by  a  capsule  of  fibrous  tis- 
sue, around  which  the  ad- 
jacent cortical  structures, 
the  tubes,  and  the  Malpi- 
ghian  bodies  are  to  be  seen 
more  or  less  comjjressed 
and  concentrically  dis- 
placed. Occasionally  are 
to  be  seen  outlying  groups  of  cells,  less  completely  encapsulated.  The 
alveolar  structure  within,  consisting  as  it  does  of  a  fibrous  matrix  exca- 
vated by  cavities  Aviiieh  are  lined  with,  or  irregularly  occupied  by,  cells 
of  epithelial  type,  has  suggested  an  origin  in  transformation  of  the  renal 
tubes.  The  cavities  are  most  irregular  in  size  and  sliape,  but  the  small- 
est, whether  seen  in  length  or  transverse  section,  sometimes  present  so 
nearly  the  dimensions  and  form  of  the  renal  tubes  that  it  is  difficult  not 
to  connect  the  morbid  witli  the  natural  spaces.  The  superabundant  and 
luxuriating  e})ithelium,  narrowed  and  elongated  by  the  mutual  pressure 
of  the  cells,  may  possibly  be  the  only  noticeable  distinction  between  the 
section  of  a  renal  tube  and  tluit  of  a  tube-like  cancer  cavity.  The  fibroid 
matrix  of  the  kidney  finds  its  analogue,  and  ajiparently  sometimes  its 
substitute,  in  that  of  the  cancer.  In  the  prinuiry  scirrhus  already  re- 
ferred to,  the  fibroid  tissue  of  the  cancer  presented  an  unbroken  conti- 
nuity with  that  of  the  kidney,  as  if  it  were  not  an  addition,  but  an  altera- 
tion.    The  fibroid  mass  imbedded  here  distinct  kidney  tubes  and  there 


Secondary  encephaloid.  The  growth  is  a  pure  intru- 
sion ;  it  displays  none  of  the  renal  structures.  (From  a 
section  prepared  by  Dr.  Watney.) 


PATHOLOGY   AND  VARIETIES    OF  RENAX   TUMORS.  55 

cancer loculi,  wliich  so  nearly  resembled  them  that  it  was  sometimes  difBcult 
to  say  wliicli  Avas  tube  and  whicli  was  cancer  cavity.  The  matrix,  which 
could  not  be  regarded  otherwise  than  as  that  of  the  cancer,  imbedded  at 
its  circumference  Malpighian  bodies,  as  if  it  were,  or  at  least  were  inse])- 
erably  joined  to,  the  matrix  of  the  kidney.  Thus,  in  some  cases  at  least, 
the  transition  from  the  structure  of  the  tumor  to  that  of  the  gland  is  as 
if  one  had  been  not  so  much  replaced  by  as  converted  into  the  other.  In 
other  instances  it  is  no  less  clear  that  the  cancer-structure  is  not  a  con- 
version but  an  intrusion,  for  it  is  separated  from  that  of  the  gland  by  a 
capsule,  on  the  outside  of  which  arc  Malpighian  bodies  and  tubes,  on  the 
inside  none.  Secondary  renal  cancer  can  often  be  traced  encircling  the 
arteries,  obviously  disconnected  from  the  glandular  structure. 

Whatever  be  the  relation  of  cancer  loculi  to  cortical  tubes,  it  would 
appear  from  the  frequent  preservation  of  the  natural  characters  of  the 
urine,  either  that  the  altered  tubes  (if  they  be  so  i-egarded)  either  do  not 
retain  their  connection  with  the  pelvis,  or  fail  to  discharge  their  contents 
into  it. 

Robin'  has  described  as  epithelioma  a  renal  cancer  which  had,  in  some 
respects  at  least,  characters  which  entitled  it  to  the  name,  though  the 
bulk  of  the  mass  more  resembled  a  degenerating  encephaloid.  The  left 
kidney  was  the  seat  of  a  tumor,  about  five  inches  square,  which  had  de- 
stroyed most  of  the  organ  save  a  cortical  shell.  The  mass  was  in  parts 
as  hard  as  the  normal  renal  structure,  in  parts  like  putty  and  in  j^arts 
diffluent  and  creamy.  Hsemorrhage  had  taken  place  into  its  structure 
in  many  places.  The  growth  consisted  mainly  of  cells,  which,  like  can- 
cer in  general,  presented  epithelial  types.  They  were  of  different  sorts 
and  sizes;  some  in  particular  approached  the  pavement  or  prismatic  form, 
and  if  these  were  derived,  which  seems  not  improbable,  from  the  mucous 
membrane  of  the  pelvis,  the  term  epithelial  may  be  properly  applied  to 
this  part  of  the  tumor.  The  pelvis  was  occupied  or  replaced  by  the 
growtli,  and  the  infundibulum  plugged  with  it.  It  is  not  impossible 
that  the  disease  may  have  begun  as  epithelioma  of  the  mucous  mem- 
brane, and  that  encephaloid  of  the  gland  may  have  been  secondary  to  it. 
A  simple  squamous  epithelioma  of  the  pelvis  of  the  kidney,  a  phthisis 
renum  cancrosa,  has  been  described  by  Rindfleisch,Mn  which  a  zone  of 
white  infiltration  extends  from  the  papillse,  which  became  early  involved, 
for  the  depth  of  two  or  three  lines  into  the  renal  substance. 

Neither  is  colloid  unknown  in  this  situation.  It  has  been  described, 
together  with  encei)haloid,  and  I  may  refer  to  a  remarkable  instance, 
which  I  brought  before  the  Pathological  Society,  in  which  a  kidney 
which  contained  some  large  calculi  had  become  dilated  into  an 
enormous  multilocular  cyst,  during  life  thought  to  be  ovarian,  and  this, 
apparently  as  a  subsequent  process,  had  been  fiHed  with  gelatinous  mate- 
rial, which  was  undistinguishable  from  colloid  cancer.  As  an  additioiuil 
peculiarity  in  this  case,  it  appeared  that  })ortions  of  the  contents  of  the 
cyst^  escaped  from  time  to  time  into  the  bladder,  with  temporary  dimin- 
ution of  the  tumor.  The  ureter  after  death  was  found  to  be  pervious 
throughout,  and  somev/hat  dilated;  the  calculi,  which  consisted  of  phos- 
phate of  lime,  were  impacted  at  one  side  of  its  entrance. 

'  Robin,  Memoire  siw  VEpithelioma  du  Rem,  quoted  by  Lebert,  "Traite  d'Ana- 
tomie  pnthol()fi;ique,"  vol.  ii.  p.  SfjO. 

'  Rindfleiscli,  Path.  Hist.  vol.  i.  p.  465  (Sydenham  translation). 
'  Path.  Trans,  vol.  xiii.  p.  137. 


56 


PATHOLOGY   AND    VARIETIES    OF    RENAL    TUMORS. 


Sarcoma. 


The  forms  of  sarcoma  which  most  often  affect  the  kidneys  are  the 
highly  malignant  round-celled  varieties,  which  start  usually  in  the  corti- 
c;il,  but  sometimes  in  the  submucous,  connective  tissue,  grow  rapidly, 
are  soft,  even  sometimes  fluctuate,  and  present  so  nearly  the  appearance 
of  encephaloid,  that  they  have  been  general  described  as  such. 

The  accompanying  sketches  will  show  the  general  characters  of  renal 
sarcoma.  The  growth  is  sometimes  thickly  encapsulated,  and  thus  sepa- 
rated   from   the    glandular 


^^/'o:^^^* 


"^ 


structures;  but  more  often 
the  partition  is  indistinct, 
and  the  growth  more  or 
less  d  iff  use,  so  that  it  spreads 
between  and  compresses  the 
tubes,  and  surrounds  the 
Mal])ighian  bodies.  Such 
growths  consist  usually  of 
round  nucleated  cells,  which 
present  all  the  variations 
in  size  which  sarcoma  per- 
mits of;  the  snnill-celled 
varieties  are  the  more  com- 
mon, but  sometimes  round 
cells  of  the  lai'gest  variety 
are  found,  as  in  the  speci- 
men represented  here. 
The  intercelhilar  substance 
is  usually  extremely  scanty. 
It  is  sometimes  to  be  noticed 
that  the  sarcoma  has  an 
alveolar  arrangement,  as 
shown  in  the  woodcut  be- 
low, which  enhances  the 
resemblance  to  true  cancer. 
The  cellulur  growth  is  often 
to  be  traced  in  especial  luxuriance  along  the  margins  of  the  new  blood- 
vessels. The  vessels  themselves  usually  have  thin  walls  and  great  cal- 
ibre, so  that  extravasation  takes  place  readily  and  profusely,  insomuch  that 
in  many  instances  the  tumor  after  death  has  presented  the  appearance  of 
mere  blood-clot,  the  sarcomatous  skeleton  revealing  itself  only  on  examina- 
tion in  section.  This  was  the  case  with  regard  to  a  tumor  represented  at 
page  58,  which  "in  the  recent  state  looked  like  a  mass  of  coagulum." 
It  is  preserved  at  Charing  Cross  Hospital,  and  I  have  to  thank  the  then 
curator,  Mr.  Bellamy,  for  allowing  me  to  open  and  examine  the  prepara- 
tion. Not  only  is  blood  thus  found  in  the  recent  state,  but  these  tumors 
are  apt  to  display  cavities  full  of  fibrin,  evidently  the  relics  of  former 
hemorrhages,  and  to  be  sprinkled  with  blood -crystals. 

Hemorrhagic  sarcoma  sometimes  presents  a  somewhat  equivocal  re- 
semblance to  lymphadenoma;  and  perhaps  if  one  were  to  judge  only  by 
the  minute  structure  it  might  not  be  possible  always  to  decide  between 
the  two;  but  the  distinction  involves  more  than  microscopical  detail — it 
relates  to  the  origin  of  the  growth  in  connective  or  lymphatic  tissue,. 


Round-celled  sarcoma  of  very  malignant  type,  from  a 
child  thirteen  months  old,  under  the  care  of  Dr.  Downes. 
The  tumor  was  spherical,  and  six  inches  in  diameter.  The 
cells,  which  were  intermediate  in  size  (between  those  re- 
presented at  pape  57i,  are  seen  mixed  with  blood-corpus- 
cles in  the  swollen  interstitial  tissue  of  the  kidnej^.  A 
large  blood-vessel  is  seen  below  and  to  the  left,  elsewhere 
the  cavities  for  tubes.  "  Cancer  "  said  to  be  hereditary  in 
family. 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TUMORS. 


5r 


association  witli  formations   elsewhere  in  one  situation  or  the 
refer  to  as   tlius  equivocal  were  both  of 


and  its 
other. 

Two  instances  I  have  to 
growths  so  largely  and  so  uni- 
formly mixed  with  extrava- 
sated  blood,  that  by  the  naked 
eye  they  were  undistinguish- 
able  from  recent  coagulum.' 
The  first  case  was  reported 
by  Dr.  >yhiphani  in  the  "  Pa- 
thological Transactions,"  and 
described  by  him  as  lymph- 
adenoma.  The  kidneys  and 
the  uterus  of  a  woman  who 
died  at  the  age  of  forty-three, 
apparently  of  bronchitis,  were 
found  to  be  studded  with 
small  elevated  patches  of  dark 
color  and  irregular  shape, 
which  were  at  first  thought  to 
be  simple  extravasations.  A 
further  examination  of  the 
spots  in  the  kidney  showed, 
however,  that  a  new  growth 
was  comprised  within  each 
hemorrhagic  patch.  This  con- 
sisted of  a  multitude  of  some- 
Avhat  irregular  nucleated  cells 


m^ 


WW^' 


Largre  rounrJ-celled  sarcoma,  from  the  case  of  Tem- 
pero.  Very  largre  irregrviliir  more  or  less  rounded  cells 
inclosed  in  a  delicate  nieshwork  which  is  inseparable 
from  the  normal  matrix  of  the  kidney. 


'^:,,/,' 


^iM< 


Small  round-celled  sarcoma,  the  cells  arrangjed  along  partitions  of  fibroid  tissue  and  blood-ves- 
sels. (From  a  preparation  at  St.  George's  Hospital  formerly  described  as  scirrhus.)  Similar 
g^rowths  found  in  other  parts  of  body. 

'  Path.  Trains,  vol.  xxiii.  p.  IfiG. 


58 


PATHOLOGY    AND    VARIETIES    OF    KENAL    TL'MORS. 


imbedded    in   a   delicate   reticulum,    which    was   apparently   a   swollen 
condition  of  the  interstitial  tissue.     The  new  growth  was  rich  in  cells  in 


.^'i;-;..' 


-Ui'.l 


^ 


3 


"^ 


'llr-^^i^^^^^'^^ 


(^      >:&>^ 


Round-celled  sarcoma  which  in  the  recent  state  resembled  a  mass  of  coagulum.  The  blood,  to 
be  (listinKuislieil  from  the  growth  by  the  small  size  of  tlie  corpuscles,  is  contained  partly  in  large 
vessels,  but  chiefly  as  extravasation  in  the  sul)stance  of  the  tumor. 


f5!??j=s 


r;l-'' 


'JJ^ 


Malignant  spindle-celled  sarcoma  consisting  of  intertwisted  bands  of  delicate  fibroid  tissue  with 
few  nuclei. 


proportion  to  the  interstitial  substance,  and  was  largel}'  mixed  with  ex- 
travasated  red  corpuscles.     The  growth  would  appear  to  be  of  connective- 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TUMORS.  59 

tissue  origin,  and  to  be  entitled  to  be  called  sarcomatous;  a  view  which, 
I  may  say,  has  the  concurrence  of  the  excellent  pathologist  who  formerly 
described  it  as  lymphadenoma.  The  marks  of  distinction,  however,  are 
not  so  sure  but  that  there  might  still  be  room  for  difference  of  opinion, 
were  regard  had  only  to  the  microscopic  characters  and  not  to  the  organic 
situation. 

The  next  instance  was  brought  under  my  notice  by  Dr.  Grigg,  who 
sent  me  the  kidney  of  an  infant,  whicli  proved  to  be  the  seat  of  a  growth 
in  some  respects  similar  to  that  already  described.  The  cellular  inter- 
space between  the  gland  and  the  pelvic  mucous  membrane  had  been  ac- 
acurately  and  uniformly  filled  with  what  looked  like  recent  blood-clot.    It 


^)7  // 


1,         i^J//-^^    '■s.-Ife;^/      /* 


Malignant  spindl-^  celled  sarconxi,  the  twisted  fibrous  ti&bue  iiivoUing  a  number  of  cavities  con- 
taining shapeless  dei)ris 

had  the  color  and  somewhat  tlie  granular  texture  of  raspberry  jam,  a 
shade  lighter^  that  is,  than  sim[)le  coa.^alum.  The  maximum  thickness 
of  this  mass  was  about  half-an-incii.  Hardened  and  examined  in  section, 
it  proved  to  be,  as  had  been  conjectured,  a  cellular  growth,  into  the  inter- 
stices of  which  bleeding  had  occurred.  It  consisted  of  a  mass  of  small 
cells  or  nuclei,  much  like  white  blood-corpuscles;  these  were  sometimes 
in  apparent  contact  with  each  other,  but  in  places  were  separated  by  the 
threads  of  a  very  definite  reticulum  composed  of  small  si)indle-cells.  In 
some  places  the  mass  was  traversed  by  thick  bars  of  common  fibrous  tis- 
sue. It  contained  in  places  crowds  of  red  blood-corpuscles  and  large 
sprinklings  of  haematin.  Blood-vessels  of  considerable  size  were  found 
in  it,  their  edges  in  some  places  fringed  with  extravasated  blood.  The 
mass,  though  in  some  parts  not  unlike  a  lymphoid  growth,  and  in  others 
like  a  mere  extravasation,  presented  on  the  whole  rather  the  characters  of 
sarcoma,  with  v/hich  accordingly  it  is  classed. 

Although  the  round-celled  sarcoma  is  the  more  common  renal  form, 
the  spindle-celled  variety  is  not  unknown.     A  remarkable  instance  of  tliis 


60  PATHOLOGY    AND    VARIETIES    OF    KENAL    TUMOKS. 

kind,  which  might  be  called  fibro-plastic  or  fibro-recurrent,  is  illustrated 
by  the  woodcuts  on  the  preceding  pages. 

The  tumor  is  described  in  the  next  chapter.     Though  hard  and  slow 
of  growth,  it  proved  eminently  malignant  in  character. 


Fibrous  and  Fibro-fatty  Tumors. 

Tumors  which  have  been  thus  described  would  probably  in  most  in- 
stances fall  within  the  definition  of  sarcoma,  or  at  least  be  so  nearly  allied, 
to  it  as  scai'cely  to  call  for  separate  consideration.  Some  years  ago  I  ex- 
hibited a  large  renal  tumor'  as  fibro-fatty — a  term  which  its  constitution 
appeared  to  Justify;  it  consisted  of  a  gray  translucent  fibrous  basis,  in 
which  no  cells  or  nuclei  could  be  found,  which  inclosed  a  yellow,  opaque 
structure  chiefly  composed  of  aggregated  oil-globules.  Dr.  Bristowe* 
produced,  as  a  companion  to  this,  another  renal  tumor  whicli  presented 
precisely  tlie  same  admixture  of  fibrous  tissue  and  oil-globules.  I  am 
now  enabled,  by  means  of  methods  of  section  which  were  not  in  use  when 
these  growths  were  presented,  to  add  to,  and  in  one  respect  to  correct, 
the  descri})tion  of  the  one  for  which  I  am  responsible.  Though  consider- 
able districts  of  this  consist,  as  described,  of  mature  fibrous  tissue,  yet  in 
other  parts  it  proved  to  be  densely  nucleated,  notwithstanding  that  the 
nucleation  was  not  apparent  under  the  rougher  methods  by  whicli  the 
growth  was  at  first  examined.  It  was  also  traversed  by  wide  thin-walled 
blood-vessels,  and  had,  in  short,  the  characteristic  structure  of  a  small- 
celled  sarcoma.  The  growth,  in  fact,  is  but  a  variety  of  sarcoma  in 
Avhich  extensive  fatty  degeneration  has  occurred. 

Simple  fibrous  tumors  have  been  described  in  the  same  relation,  but 
it  is  not  improbable  that  further  examination  might  i^h^ce  them  in  the 
same  category.  Dr.  Wilks'  displayed  one  about  as  large  as  a  child's 
head,  in  which  the  form  of  the  kidney  was  almost  exactly  preserved.  It 
was  very  hard  and  looked  like  fibro-cartilage,  but  proved  to  consist  of 
fibrous  tissue  only.  It  had  been  of  such  a  size  as  to  attract  notice  as  an 
abdominal  tumor  for  six  years;  four  years  before  this  there  had  been 
haematuria  and  pain  in  the  loins;  so  that  ten  years  may  fairly  be  assigned 
as  the  duration  of  the  growth.  Beside  such  larger  tumors  as  have  been 
referred  to,  small  fibromata,  from  the  size  of  a  pea  downwards,  have  been 
found  harmlessly  disposed  in  the  midst,  of  healthy  renal  tissue.  Tubes 
have  been  traced  into  them,  and  they  have  been  thought  to  be,  as  indeed 
are  most  renal  tumors  of  the  sarcomatous  kind,  mere  exaggerations  of  the 
interstitial  tissues.'' 

Melanosis. 

Black  growths  or  deposits  have  been  met  with  in  the  kidney,  and 
sometimes  described  as  cancer,  though  it  is  probable  that  the  term,  in 
its  present  ]-estricted  sense,  would  not  always  apply.  Walshe  observes 
that   the  melanotic   discoloration  of  cancerous   masses  is  occasionally, 

'  See  Path.  Trans,  vol.  xiv.  p.  187,  where  the  growth  is  represented  in  a  colored 
plate. 

■'  Ibid.  p.  190. 

*  Path.  Trans,  vol.  xx.  p.  244. 

■•  Rindfleisch,  Path.  Hist.  (Sydenham  Society),  vol.  ii.  p.  168. 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TDM0R8. 


61 


though  rarely,  met  with  iti  this  organ/  and  the  similar  pigmentation  of 
sarcomatous  tumors  is  not  au  unfamiliar  experience.  But  melanotic 
formations  may  take  place  independently,  as  it  would  seem,  of  any  other 
morbid  growth,  simply  as  a  development  of  pigment-cells  in  the  intersti- 
tial tissue  of  the  organ.  The  accompanying  woodcut  represents  a  typi- 
cal example  of  this  in  the  Museum  of  the  Royal  College  of  Surgeons, 
which,  by  the  courtesy  of  the  curator,  Professor  "Flower,  I  was  enabled  to 
examine  with  the  microscope.     The  black  spots,  which  were  unattended 


Scattered  melanotic  deposits  in  kidney.    (From  a  preparation  at  the  College  of  Surgeons.) 

with  any  obvious  swelling  or  displacement  of  structure,  were  caused  by 
the  sprinkling  of  the  interstitial  tissue  with  large  pigment-eells,  or  black 
debris,  which  liad  apparently  resulted  from  their  disintegration. 

The  cells  were  situated  wliolly  in  the  intertubular  district  of  the  kid- 
ney, leaving  the  tubes  and  Malpighian  bodies  unaffected,  but  often 
strikingly  outlined  by  the  black  matter.     There  was  no  evidence  of  new 


1  Walshe,  On  Cancer,  p.  380. 


62 


PATHOLOGY    AND    VAKIETIES    OF    RENAL   TUMORS. 


Gbroid  growth  or  stroma.  It  is  to  be  noted  that  the  discoloration 
affected  the  capsule  wliere  this  was  op])osite  to  the  black  spots.  In  the 
same  collection  is  another  kidney,  which  is  uniformly  blackened  through- 
out by  a  change  to  which  the  same  name  would  be  applied.  At  the 
London  Hospital  is  a  kidney  apparently  similar  to  the  first-mentioned, 
in  which  the  structure  is  dotted  with  black  deposits  varying  in  si-ze  from 
pins'-heads  to  peas.  These  have  a  powdery  look,  and  are  abruptly  cir- 
cumscribed, looking  as  if  lampblack  had  been  inserted  into  round  cavi- 
ties.    There  is  no   history.     At  King's  College  are  several  specimens. 


Sf^'^^MW- 


Magnified  section  of  one  of  the  black  spots  represented  in  the  preceding  woodcut,  showing 
melanotic  cells  and  granules  in  interstitial  tissue.    The  Malpighian  bodies  and  tubes  are  exempt. 

showing  melanotic  deposition  in  the  same  organ,  in  one  of  which  it  is 
associated  witli  villus.  Clinically  the  history  of  melanosis  is  that  of  the 
growth  with  wliich  the  pigment  is  associated;  in  addition  '  to  which  we 
have  the  fact  that  in  certain  instances  the  urine  has  been  found  to  con- 
tain black  pigment,  either  in  casts,  granules,  or  diffused  color. 

Villus. 

Villous  disease  of  the  kidney  is  of  great  rarity.  In  most  of  the  cases 
of  which  wc  have  knowledge,  it  appears  to  be  analogous  to  the  Avell- 
known  villous  disease  of  the  bladder,  Avhich  is  not  malignant,  and  which 
belongs  especially  to  the  trigone.  A  striking  example  of  villous  disease 
of  the  kidney  was  related  at  the  Pathologic-'^l  Society'^  by  the  late  Mr. 
Campbell  de  Morgan;  and  by  his  courtesy  I  was  enabled  to  have  made 
the  representation  which  is  annexed. 

This  was  obtained  from  the  body  of  a  woman  who  had  died  at  the 
age  of  seventy-six,  after  an  operation  for  strangulated  hernia.     During 


'  Paper  by  Dr.  Hilton  Fagge.  Path.  Trans,  vol,  xxviiL  p.  172, 
« Path.  Trans,  vol.  xxi.  p.  239. 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TCMORS. 


63 


the  preceding  two  years  the  urine  had  been  albuminous,  and  she  had  had, 
at  intervals  of  from  two  weeks  to  two  months,  attacks  of  haematuria,  at- 
tended with  pain  in  the  renal  region,  so  profuse  as,  on  two  occasions,  to 
endanger  life.  On  posi-7)wrfe!u  examination  the  pelvis  of  the  left  kidney 
was  found  to  be  dilated  and  full  of  what  at  first  appeared  to  be  a  mass  of 
thick  shreddy  pus.  From  this  a  fluid  separated,  which  contained  not  pus- 
corpuscles,  but  nucleated  cells,  granular  corpuscles,  and  the  debris  of  cells, 
such  as  would  give  the  impression  that  they  belonged  to  a  cancerous 


^'''fW^' 


Villus  of  kidney  (from  preparation  at  Middlesex  Hospital),  described  hy  Mr.  Campbell  de  Mor- 
gan.   Tlie  kidney  is  laid  open,  and  the  growtii  seen  to  hang  freely  from  the  pelvis. 

growth,  leaving  behind  a  soft  mass  of  the  size  of  a  damson,  which  on 
washing  spread  itself  out  into  the  shaggy  beard-like  growth  which  is 
represented.  The  larger  portion  grew  from  tlie  wall  of  the  ])elvis  by  a 
broad  but  thin  pedicle,  wliile  smaller  tufts  were  attached  to  other  parts 
of  tlie  same  membrane.  A  microscopic  examination  of  the  villi  showed 
that  many  of  them  were  coated  with  epithelium.  They  resembled  those 
found  in  the  non-cancerous  villus  of  the  bladder,  though  the  latter,  as 


64 


PATHOLOGY    AND    VARIETIES    OF    KENAL    TUMORS. 


Mr.  (le  Morgan  observes,  are  not  commonly  surrounded  with  an  exuda- 
tion so  full  of  nucleated  cells.  The  compact  portion  of  the  tumor  was 
made  up  of  a  delicate  fibrous  stroma,  from  which  a  juice  containing 
nucleated  cells  exuded.  But  that  this  structure  was  not  truly  cancerous 
was  inferred  from  a  disposition  within  the  stroma  to  forms  like  those 
which  constituted  the  villi,  wliile  in  cancerous  growths  with  villous  sur- 
faces tiie  structure  is  purely  that  found  ordinarily  in  cancer.  The  ab- 
sence of  secondary  deposits  bears  out  this  view. 

A  somewhat  similar  case  is  reported  by  Dr.  Murchison  in  juxtaposi- 
tion with  Mr.  de  Morgan's.  A  man  sixty-five  years  of  age  was  subject  to 
attacks  of  profuse  iiaematuria  for  fourteen  months  before  his  death. 
Latterly,  after  severe  pains  shooting  from  the  right  kidney  to  the  pubes, 
he  became  drowsy  and  nearly  unconscious,  with  dry  tongue,  muttering 
•delirium,    hiccough,    vomiting,    and   frequent    convulsive    movements. 

After  death  these  symp- 
toms, which  had  been 
correctly  regarded  as  urae- 
mic,  were  explained  by 
the  obstruction  of  both 
ureters  by  coagulum,  and 
the  filling  of  the  jielvis  of 
the  right  kidney  with  the 
same  material.  The  urae- 
mia was  evidently  the  re- 
sult of  obstruction,  but 
though  no  urine  is  men- 
tioned as  having  been 
passed  during  the  last  four 
days,  its  suppression  is  not 
\  ' '  ^---y^'',--''''''.' :{ \\W^fM^J^'^'i^^'^A  distinctlv  stated. 

>,■,..,  .      //^^'"■'/^■■■■'r  ■' ^^  '^^Wiu'<-0  ^^^^  bladder  was  stud- 

Mlii!,.!      ',    ,,>  .'. ..,';j''i-^:sKf'  ded  with  long  villous  pro- 

cesses, especially  about 
the  orifices  of  the  ureters; 
while  the  pelvis  and 
calyces  of  each  kidney 
were  similarly  beset.  These 
were  from  one  to  several 
lines  in  length  ;  they  were  covered  Avith  a  thin  layer  of  epithelium,  and 
included  a  ca})illary  vessel  full  of  blood.  Tlicre  was  no  secondary  deposit, 
nor  any  formation  of  the  ordinary  type  of  cancer. 

In  Guy's  Museum,  there  is  a  preparation  which  displays  a  large  amount 
of  villous  growth  in  connection  with  a  diseased  kidney,  which  is  enor- 
mously dilated,  evidently  from  calculi,  one  of  which  still  remains  in  one 
of  the  calyces.  The  colon  is  adherent,  and  its  cavity  is  connected  with 
that  of  the  kidney  by  a  sinuous  opening.  From  the  lining  of  the  pelvis 
hangs  a  quantity  of  shaggy  villous  growth,  and  to  a  different  part  of  the 
same  cavity  is  attaclied  a  quantity  of  more  solid  pendent  matter,  which 
looks  like  villous  structure  associated  with  some  more  solid  material. 

The  disease  is  described  in  the  catalogue  as  malignant,  but  there  is 
no  reference  to  cancer  or  growth  in  any  other  organ.  Through  the  kind- 
ness of  Dr.  Hilton  Fagge,  I  was  enabled  to  examine  this  interesting  speci- 
men with  the  microscope.  The  solid  growth  of  whicli  the  walls  chiefly 
•consisted  was  made  up  of  spindle  cells  of  the  sarcomatous  type,  with  inter- 


:(•  ' 


Section  from  the  cortical  structure  of  the  villous  kidney 
<(at  Gu3-'s  Hospital).  A  Malpighian  body  is  seen  surrounded 
•by  nucleated  fibroid  growth  of  sarcomatous  character. 


I 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TUMORS. 


65 


Tills  here  and  there  in  which  numbers  of  small  round  nuclei  were  closely 
packed.  These  (vere  related  to  the  interstitial  tissue  of  the  kidney,  and 
could  often  be  traced  abundantly  surrounding  the  Malpighian  bodies, 
which  themselves  were  unaffected.  The  vascular  loops  which  constituted 
the  villi  were  thin  tubes  of  simple  and  bare  membrane.  The  growth  is 
clearly  related  to  sarcoma  rather  than  cancer.  Its  apparent  origin  in  cal- 
culous irritation  is  of  interest. 

In  the  Museum  of  King's  College  is  a  preparation  showing  the  concur- 
rence in  the  kidney  of  villous  structure  with  melanosis. 

The  symptoms  of  villous  disease  of  the  kidney  are  sufficiently  indi- 


Single  detached    pendent  blood-vessel.    (From  preparation  referred  to  in  preceding  figure.) 
The  process  displays  little  more  than  thin  and  bare  membrane. 

cated  in  the  preceding  cases.  Attacks  of  hasmaturia,  which  completely 
intermit,  but  so  profuse  as  to  endanger  life;  possibly  some  dull  pain  in 
the  lumbar  region,  but  no  acute  pain  anywhere;  urine  simply  mixed  with 
blood,  without  deposit  to  indicate  its  source,  or,  if  we  may  reason  from 
the  analogy  of  the  vesical  villus,  with  which  indeed  tlie  renal  villus  ap- 
]iear3  to  be  generally  associated,  containing  loops  of  blood-vessel  without 
surrounding  tissue.  Tliese  are,  of  course,  pathognomonic;  but  they  may 
be  searched  for  repeatedly  and  in  vain.  On  the  other  hand,  though  the 
5 


66  PATHOLOGY    AND    VARIETIES    OF    RENAL    TUMORS. 

disease  be  villus,  it  is  possible,  if  the  bladder  be  affected,  that  the  urine 
may  abound  with  epithelium,  the  result  of  secondary  cystitis.  Tliis  in- 
deed, besides  the  blood,  may  be  the  only  product  of  a  villous  growth. 
Its  situation  as  between  the  kidney  and  bladder  must  be  determined  by 
the  general  indication  of  the  symptoms,  as  pointing  to  one  organ  or  the 
other  as  the  seat  of  disease. 

Lymphadenoma. 

The  kidney  is  by  no  means  an  infrequent  seat  of  lymphadenoma. 
The  growth  as  it  occurs  in  this  organ  presents  points  of  contact  with 
sarcoma,  insomuch  that  tumors  occur  of  which  it  is  difficult  to  determine 
whether  they  belong  to  one  or  tlie  other;  one  part  of  such  a  mass  may 
resemble  a  growth  of  lymphatic  origin  and  another  part  be  indis- 
tinguishable from  one  of  the  small-celled  sarcomata  already  described. 

To  take  first  the  common  and  unequivocal  form  of  the  disease,  it  oc- 
curs in  the  kidney  only  as  part  of  a  general  disorder,  formations  of  the 
same  nature  being  found  also  in  the  lymphatic  glands,  probably  in  the 
spleen,  and  occasionally  in  the  liver  and  lung.  The  importance  of  the 
disorder  is  rather  general  tlian  local,  or  so  far  as  local  symptoms  ob- 
trude themselves,  they  relate  to  the  swollen  glands  rather  than  to  any 
internal  organs.  The  renal  symptoms,  if  such  there  be,  have  been  hith- 
erto overlooked  in  the  presence  of  the  signs  of  lymphatic  anasmia,  which 
mark  the  fatal  tendency  of  the  disease.  It  is  worth  noting  that,  in  Dr. 
Murchison's  case,'  which  furnishes  the  most  extreme  example  of  renal 
lymphadenoma  which  I  am  acquainted  with,  the  urine  was  found  to  be 
pale,  clear,  and  free  from  albumin. 

The  appearance  of  the  kidneys  under  the  disorder  is  sufficiently  strik- 
ing. Bounded  masses  of  variable  size  beset  the  renal  substance,  more 
especially  in  the  cortex,  and  present  themselves,  often  numerously,  under 
the  capsule.  In  this  position  they  usually  display  a  circular  outline, 
though  when  cut  at  right  angles  to  the  surface,  they  may  give  one  which 
is  elongated  or  pear-shaped.  In  the  typical  example  figured  by  Dr. 
Murcliison,  the  masses,  of  which  about  a  hundred  are  displayed  on  the 
lateral  aspect  of  one  kidney  which  the  drawing  presents,  vary  in  diameter 
from  about  three-eighths  of  an  inch  to  the  size  of  a  mustard-seed.  The 
growths,  however,  have  often  been  known  to  exceed  in  size  the  largest  of 
these.  They  are  yellowish-wliite,  somewhat  like  large  masses  of  tuber- 
cle, but  are  harder,  closer  in  grain,  and  less  apt  to  caseate.  Microscop- 
ically, they  present  the  characters  which  belong  to  lymphoid  growths 
generally — a  strongly  marked  fibrous  reticulum,  which  blends  with  the 
intestinal  tissue  of  the  organ,  in  the  substance  of  which  are  crowds  of 
small  circular  uniform  nuclei,  and  in  its  spaces  nucleated  cells. 

Leukh^mic  Tumors  or  Extravasations. 

"White  marrow-like  tumors,  consisting  of  white  blood-corpuscles  in 
a  very  delicate  reticulum,  varying  in  size  from  a  mere  dot  to  a  cherry, 
have  been  described  as  occurring  in  the  kidney  in  connection  with  the 
general  condition  of  leukhaemia.^ 

'  Path.  Trans,  vol.  xx.  p.  192.  "With  the  report  of  the  case  are  excellent  illus- 
trations of  tlie  naked-eye  and  jnicroscopic  appearances.  See  also  case  published 
by  Dr.  Coupland,  Path.  Trans,  vol.  xxviii.  p.  126. 

°  Riudfleisch,  loc.  eit.  vol.  ii.  p.  168. 


I 


I 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TU1VI0R8.  67 

Sometimes  the  extravasations,  thongli  mainly  consisting  of  white 
corpuscles,  present  so  much  the  appearance  of  ordinary  hemorrhage  that 
they  are  not  to  be  distinguished  by  the  naked  eye  from  such  sanguineous 
outbreaks  as  have  been  described  in  connection  with  some  of  the  varie- 
ties of  sarcoma. 

Dr.  Greenfield  gives  an  instance  of  this  in  the  "  Pathological  Trans- 
actions "  for  1878.*  A  child  four  years  old,  born  of  syphilitic  parents, 
became  the  subject  of  purpura,  and  lapsed  into  a  condition  of  extreme 
ansemia,  in  which  it  died.  The  blood  displayed  during  life  an  excess  of 
white  corpuscles.  Not  to  mention  many  external  ecchymoses,  the  most 
remarkable  changes  found  after  death  were  in  the  liver  and  kidney,  and 
were  due  to  the  extrusion  of  white  corpuscles  into  the  interstitial  tissue 
of  these  organs.  In  the  liver,  this  took  the  form  of  a  white  veining,  cor- 
responding with  the  interlobular  divisions  of  the  portal  canals,  which 
was  found  to  consist  of  extravasated  leucocytes.  In  the  kidneys,  patches 
of  extravasated  blood  were  found  underneath  the  capsule.  The  cortical 
surface  was  marked  by  large  irregular  hjemoi'rhagic  blotches,  which  were 
slightly  raised,  and  were  but  the  bases  of  cone-shaped  haemorrhagic  masses, 
which  penetrated  deeply  into  the  organ.  These  masses  consisted  of  ex- 
truded leucocytes,  which  had  collected  abundantly  between  the  tubes 
and  outside  the  Malpighian  bodies.  These  were  not  separated  by  any 
stroma,  save  a  delicate  interlineation  of  fibrinous  threads. 


Angioma. 

Cavernous  tumors,  such  a-s  are  found  in  the  liver,  have  been  described 
in  the  kidney,  but  these  have  no  practical  importance. 


Syphiloma. 

Syphiloma  must  be  briefly  mentioned  as  a  renal  tumor,  though  the 
local  is  of  quite  secondary  importance  to  the  constitutional  affection. 

A  syphilitic  tuber  as  large  as  a  small  potato  is  described  and  figured 
by  Dr.  Moxon,^  occujiying  the  renal  glandular  substance  nearly  from  the 
pelvis  to  the  capsule.  A  minute  examination  showed  that  the  tumor  es- 
sentially consisted  of  a  profuse  nuclear  growth  in  the  intertubular  por- 
tion of  the  organ.  Both  kidneys  were  enhirged  and  lardaceous;  the  pair 
weighed  twenty-two  ounces.  The  enlargement  of  the  left,  in  which  was 
the  tuber,  was  felt  from  the  front  during  life.  The  jiatient  had  the  gen- 
eral signs  of  syphilis,  together  with  general  dropsy  and  pale  albuminous 
urine.  The  latter  symptoms  were  probably  to  be  attributed  to  the  lar- 
daceous disease;  the  localized  swelling,  however,  is  more  distinctive. 

A  few  similar  tumors  have*  been  described  by  other  writers;  they  ap- 
pear to  have  been  invariably  imbedded  in  lardaceous  kidneys,  by  wliich 
the  symptoms  are  necessarily  masked. 

I  have  seen  patches  of  fibrosis  in  the  kidney  in  connection  with  con- 
genital syphilis;  it  is  probable  that  general  fibrosis  of  the  kidney,  as  of 
the  liver,  may  sometimes  have  this  origin. 


'  Path.  Trans,  vol.  xxix.  p.  298,  plate  xiv. 

'  Ouy's  Hospital  Reports  for  1868,  p.  393,  plate  i.     See  also  Cornil,  Joum.  de 
I'Anat.  et  Phys.  1865,  p.  96. 


68  pathology  and  varieties  oe  kenal  tum0k8. 

Fatty  Tumors  and  Transformation's. 

The  kidney  offers  no  exception  to  the  law  that  morbid  growths  are 
but  exaggerations  of  normal  structures.  Thus  the  growths  wliich  arise 
in  this  organ  are  conijniratively  few;  possibly  cancer  from  the  tubes, 
certainly  sarcoma  from  tlie  interstitial  structure.  This  structure  may 
also  degenerate  into  oil,  and  in  certain  circumstances  become  converted 
into  fat,  as  is  rendered  probable  by  the  occasional  substitution  of  the 
glandular  tissue  by  this  material.  Under  irritation,  more  particularly 
such  as  is  connected  with  stone,  pyelitis,  or  the  retention  of  urine,  fat  is 
apt  to  increase  in  connection  with  the  capsule  and  in  the  pelvic  or  inter- 
lobular cellular-tissue,  until  it  may  happen,  should  the  growth  be  associ- 
ated, as  it  often  is,  with  a  corresponding  atrophy  of  tlie  glandular  struc- 
ture, that  fat  may  largely  take  the  place  of  the  shrunken  oi-gan.  This  is 
a  form  of  fatty  substitution  rather  than  tumefaction,  and  there  is  another 
change  to  winch  the  same  term  may  be  applied.  Instances  have  been 
described  in  which  the  whole  glandular  ticsue  of  the  organ  has  been 
transformed  into  fat,  in  which  little  or  no  trace  of  the  proper  structure 
remains,  though  the  cones  and  the  cortex  are  distinguishable  from  each 
other. ' 

Circumscribed  growths  of  fat,  of  the  nature  of  fatty  tumors,  have 
been  described  underneath  the  cajasule,  but  these  are  small  and  of  no 
practical  importance. 

Bony,  Calcareous,  and  Cartilaginous  Groavths. 

True  bone  very  rarely  occurs  as  a  renal  growth,  though  an  instance  has 
been  referred  to  in  connection  with  ])yelitis  (p.  17).  Cartilage  is  of  less 
irequent,  and  even  doubtful,  occurrence. 

There  are  many  preparations  in  museums  which  show  formations 
"within  the  kidney  of  bony  hardness;  these  appear  to  be  usually  derived 
from  the  transformation  of  hydatids.  There  is  such  a  specimen  at  Guy's 
Hospital,  which  is  described  in  the  catalogue  as  a  "  kidney  containing  a 
mass  of  bones."  Under  the  microscope,  however,  no  trace  of  osseous 
structure  could  be  seen;  the  mass  was  simply  cretaceous.  There  is  a 
preparation  at  the  College  of  Surgecuis,  in  which  the  kidney  of  a  man 
who  for  ten  years  had  passed  hydatids  in  the  urine  is  transformed  into 
an  irregular  ovoid  mass  of  cretaceous  matter,  which  has  lost  all  renal 
semblance.' 

Instances  have  also  been  described  in  which  the  capsule  of  the  kidney 
has  been  partially  "ossified,"  to  use  the  term  commonly  applied  to  the 
change.  J)r.  Elliotson  sent  to  M.  Eayer  an  atrophied  kidney,  of  which 
Jjoth  the  pelvic  mucous  membrane  and  the  capsule  were  represented  by 
hard  shells,  but  whether  bony  or  only  calcareous  we  have  no  means 
of  ascertaining,  probably  the  latter.  The  same  writer'  gives  a  rep- 
resentation of  a  tumor  of  bony  consistence,  as  large  as  an  orange,  which 
occupies  one  end  of  the  kidney.     This  was  enveloped  in  a  cyst  of  carti- 


'  Rayer,  loc.  cit.  vol.  iii.  p.  616.  Ebstein,  Ziemssen's  Cydopcedia,  vol.  xv.  p. 
635.     Dr.  HuUett  Browne,  Path.  Trans,  vol.  xiii.  p.  131. 

^  Guy's  Hospital  Museum,  2,034  :  College  of  Surgeons,  No.  1,925a.  See  also  a 
preparation  at  St.  Bartholomew's  Hospital,  No.  26,  17. 

*  Rayer,  Maladies  des  Reins,  vol.  iii.  p.  608.     Atlas,  plate  xxxvi.  fig.  6. 


PATHOLOGY    AND    VARIETIES    OF    RENAL    TUMORS.  69 

laginous  hardness;  and  altogether  the  description  is  suggestive  that  it  may 
have  been  the  residuum  of  a  suppurating  hydatid. 

Abscesses,  Avhether  arising  in  hydatids  or  in  tubercle,  or  independent 
of  either,  may  become  quiescent  "in  the  kidney,  and  be  represented  only 
by  the  cretaceous  residue  of  the  pus  they  have  once  contained.  Thus 
the  kidney  may  be  practically  destroyed  by  pyelitis,  and  the  products 
shut  up  in  the  pelvis,  until  at  last  nothing  remains  but  an  innocuous 
though  useless  cyst,  containing  a  mass  of  chalky  or  mortar-like  substance. 


CHAPTER  YII. 

CLIXICAL    HISTORY,    SYMPTOMS,    AXD    TREATMENT     OF 
MALIGXANT  DISEASE  OF  THE  KIDNEY. 

Touching  the  symptoms  of  malignant  disease  of  the  kidney,  no  dis- 
tinction is  possible  between  cancer,  properly  so-called,  and  tlie  sarcoma- 
tous growths  which  take  their  rise  in  the  connective  tissue  of  the  organ. 
And  in  regard  to  the  literature  of  the  subject,  it  is  needful  to  bear  in 
mind  that  what  is  generally  described  as  cancer  is  seldom  to  be  more 
nai'rowly  interpreted  than  as  an  encroaching  and  destructive  growth. 

In  most  cases  the  cause  is  undiscoverable.  Those  which  present  them- 
selves to  our  notice  are  of  two  kinds:  mechanical  violence  and  stone 
•within  the  kidney.  Hereditary  predisposition  is  not  strongly  declared, 
though  sometimes  apparent,  as  in  the  instance  Avhicli  is  illustrated  by  a 
■woodcut  at  page  56.  Falls,  kicks,  and  violent  blows  of  several  kinds 
■which  appear  often  to  have  affected  the  lateral  aspect  of  the  trunk,  towards 
which  the  kidney  is  more  exposed  than  directly  to  the  front  or  rear,  have 
been  mentioned  by  many  writers  in  this  relation.  Ha^maturia  has  been 
recorded  in  most  instances  iis  an  immediate  result  of  the  accident.  The 
growth  has  made  its  appearance  at  varying  periods  subsequently  :  in  a 
case  mentioned  by  Bright  in  little  more  than  three  months  after  the  fall 
down-stairs  to  which  it  was  attributed,  in  other  instances  in  six  months, 
in  another  in  two  years.  Renal  stones  are  equally  distinct  antecedents 
of  renal  growths,  whether  the  nature  of  the  sarcoma  or  cancer,  though 
they  have  attracted  less  attention  in  this  relation  than  have  injuries  by 
■violence.' 

A  case  of  malignant  sarcoma  which  ensued  upon  years  of  suffering 
from  renal  calculi  is  reported.  An  instance  of  villous  disease  associated 
vvitli  sarcomatous  tliickening.  is  referred  to  at  page  64,  and  an  instance 
of  colloid  subsequent  to  calculous  obstruction  at  page  55.  There  ap- 
2)ears,  indeed,  to  be  no  form  of  renal  growth  which  may  not  be  insti- 
gated by  this  irritant.  Pathology  abounds  with  instances  in  which  ma- 
lignant and  other  growths  have  been  started  by  accidental  irritations; 
cancer  of  the  gall-bladder  from  biliary  calculus  is  a  parallel  instance  to 
cases  in  which  the  pelvis  is  the  seat  of  the  villous  or  other  growth 
sequent  upon  renal  stone;  cases  where  the  growth  has  begun  apparently 
in  the  substance  of  the  organ  are  less  easily  to  explain  as  the  result  of 
pelvic  irritation;  but  that  stone  is  more  often  a  precursor  of  renal  growths 
than  can  be  explained  by  chance  concurrence  is  certain. 

The  symptoms  by  which  malignant  disease  of  the  kidney  is  commonly 
declared,  are  tumor,  pain,  hajniaturia,  cachexia,  which  must  be  held  to 
include  loss  of  flesh  and  strength,  and  embrownment  of  the  skin,  and  the 
several  signs  which  denote  the  extension  or  transplantation  of  the  growth 

'  Abdominal  Tumors  (Sydenham  Society),  p.  230. 


CLINICAL    ASPECT    OF    MALIGNANT    TUMORS.  71 

to  other  organs,  as  to  the  spine  or  hiiig.  In  a  large  majority  of  cases  the 
renal  swelling  presents  itself  as  a  ])alpable  tumor;  of  all  the  signs  of 
malignant  renal  disease  this  is  the  most  constant.  The  swelling,  partic- 
ularly in  children,  may  appear  as  a  prominent,  or  even  as  an  exception- 
ally large,  abdominal  tumor.  The  relations  and  means  of  identifying 
renal  tumors  have  been  already  stated  (p.  37);  it  only  remains  to  say, 
with  regard  to  those  of  malignant  character,  that  they  are  not  always 
conspicuous;  deep  handling  of  the  belly  may  be  needed  for  the  detection, 
and  even  this  may  be  ineffective  until  the  muscular  resistance  has  been 
overcome  by  means  of  chloroform.  The  enlargement  of  a  renal  growth 
is  almost  always  chiefly  in  front,  though  some  degree  of  fulness  and 
levelling  uj)  of  hollows  is  to  be  felt  in  the  lumbar  region.  As  an  excep- 
tion must  lie  mentioned  a  man  who  was  in  St.  George's  Hospital,  under 
the  care  of  Mr.  Holmes,  and  whose  case  is  related  in  the  "Pathological 
Transactions." '  A  large  pulsating  swelling  occupied  the  lumbo-sacral 
region  on  the  left  side,  and  emitted  a  low  soft  blowing  murmur.  This 
was  fonnd  to  have  been  produced  by  a  highly  vascular  malignant  growth 
belonging  to  the  corresponding  kidney,  which  was  enlarged  thereby  to 
the  weight  of  30  oz.  Among  nineteen  cases  of  malignant  tumor  primary 
to  the  kidney  of  which  I  have  the  particulai's  before  me,  there  were  but 
three  in  which  a  tumor  was  not  detected  during  life.  Among  the  three 
exceptions  was  one  in  which,  though  a  large  tumor  existed,  and  was  sus- 
pected, tenderness  from  peritonitis  forbade  its  being  adequately  sought; 
in  one  of  the  others  a  tumor  which  could  have  been  easily  felt  escaped 
notice,  for  no  other  reason  than  that  it  was  not  felt  for;  in  the  third,  the 
renal  mass  weighed  17^  oz.,  and  possiljly  would  have  been  detected  had 
not  implications  of  the  brain  or  skull  withdrawn  attention  from  what 
was  probably  the  first  seat  of  the  growth.  Thus  in  all  a  renal  tumor  was, 
if  not  perceived,  at  least  jierceivable;  those  which  escaped  notice  were 
not  indeed  so  small  as  some  wliich  were  found.  But  though  renal 
growths  are  generally  to  be  distinguished  as  palpable  swellings,  they  are 
not  so  easily  to  be  known  as  renal;  in  one  of  the  cases  referred  to,  the 
tumor  was  supposed  to  be  a  slight  enlargement  of  the  spleen,  in  another 
to  be  an  ovarian  cyst. 

Next  to  swelling  perhaps  comes  pain  in  order  of  frequency  as  a  symp- 
tom of  malignant  disease  of  the  kidney.  Children  with  large  soft  tumors 
often  apj)ear  to  be  free  from  it,  but  elder  persons  with  harder  growths 
are  seldom  so,  and  sometimes  suffer  severely  and  persistently.  The  harder 
the  growth,  as  a  rule,  tlie  greater  the  pain.  It  is  dull  and  wearying 
rather  than  acute,  and  is  not  generally  intensitied  by  movement,  these 
circumstances  marking  the  distinction  between  pain  from  this  source  and 
that  from  stone.  The  pain  of  malignant  growth  is  usually  most  marked 
^bout  the  proper  renal  region  on  the  affected  side,  and  is  accompanied  by 
tenderness,  which  may  make  the  patient  keenly  conscious  that  the  fingers 
of  the  explorer  are  exactly  adapted  to  the  seat  of  the  disease.  The  line 
of  the  ureter  and  the  testicle  are  less  affected  than  with  stone.  The  ex- 
tension of  the  pain  to  the  spinal  region,  more  particularly  if  tenderness 
over  individual  vertebrse  belonging  to  the  lower  dorsal  or  upper  lumbar 
region  can  be  recognized,  is  a  sign  of  the  extension  of  the  disease  in  this 
direction,  and  an  indication  at  once  of  its  nature  and  of  its  impending 
termination.     Pain  down  the  thighs  may  accompany  this  extension,  and 


Vol.  xxiv.  p.  149. 


72  CLINICAL    ASPECT    OF    MALIGNANT   TUMORS. 

be  shortly  followed  by  paralysis,  first  of  the  bladder,  and  possibly  not  ex- 
tending to  an  observable  extent  further,  to  be  succeeded,  should  time 
allow,  by  paralysis  of  the  lower  limbs,  and  the  sphincter  ani,  and  uncon- 
trollable bedsores. 

Perhaps  the  next  degree  of  significance  must  be  attached  to  the  con- 
stitutional results  of  malignant  disease  in  loss  of  flesh  and  change  of 
color;  with  the  rapid  growths  of  childhood  the  complexion  may  remain 
perfectly  unaffected,  and  loss  of  flesh  be  at  least  not  observable  until 
late,  but  with  older  subjects  both  emaciation  and  tinting  of  the  skin 
may  be  very  conspicuous,  the  lean  figure  and  brown  face  possibly  giving 
a  delusive  suggestion  of  tropical  experience.  With  this,  or  apart  from  it, 
is  sometimes  an  extraordinary  failure  of  strength,  spirits,  and  vitality  ; 
the  patient  may  sicken  of  a  vague  disease,  get  thin  and  weak,  take  to  his 
bed  without  pain  or  definite  complaint,  and  at  last  die  without  giving 
up  his  secret.  Urasmia  rarely,  if  ever,  appears  as  a  result  of  renal 
growths. 

Hasmaturia  has  been  variously  estimated  as  a  symptom  of  malignant 
disease  of  the  kidney.  It  perhaps  has  no  greater  value  in  tiiis  relation 
than  as  present  in  an  important  minority  of  cases.  I  have  before  me  the 
notes  of  seventeen;  of  which  hematuria  was  known  to  have  occurred  in 
six,  in  one  of  which  it  was  probably  due  to  stone,  which  existed  as  a  com- 
plication. Eoberts,  out  of  fifty-nine  cases,  collected  mostly  "from  published 
records,  found  mention  of  this  symptom  in  thirty-one,  in  five  of  which 
there  was  intervention  of  other  possible  cause — stone,  Bright^s  disease,  or 
external  violence.  Ebstein,  in  his  larger  compilation,  found  notice  of 
haematuria  in  twenty-four  out  of  fifty  cases. 

Kenal  cancers,  though  possibly  tubal  in  their  origin,  are  commonly 
separated  by  encapsulation  from  the  })r<)per  glandular  structures ;  sarco- 
mata, though  often  diffuse,  are  interstitial  in  their  position.  Cut  off  as 
both  are  from  the  tubes  and  Malpighian  bodies,  neither,  as  a  rule,  bleed 
into  the  urinary  passages,  except  as  the  result  ©f  fungation  into  the 
pelvis,  either  by  participation  of  the  mucous  membrane  in  the  disease, 
or  by  protrusion  by  way  of  one  of  the  mammillary  processes.  Thus 
haematuria  is  by  no  means  of  necessary  occurrence,  but  when  it  does  occur 
is  constant.  Earely  in  the  history  of  such  cases  an  isolated  hemorrhago 
has  been  reported  early  in  the  disease,  where  the  urine  was  said  to  have- 
been  bloody  four  years  before  death,  and  to  have  recovered  its  normal 
cliaracters.  Possibly  in  such  circumstances  the  kidney  becomes  con- 
gested under  the  early  process  of  morbid  growth,  but  the  rule  that  hem- 
orrhage in  connection  with  renal  tumors  indicates  ulceration  into  the 
urinary  passages  admits  of  few  exceptions.  The  bleeding,  once  begun, 
is  generally  continuous,  if  left  to  itself,  though  it  does  not  entirely  ignore 
styptics.  It  is  often  profuse  enough  to  cause  anaemia,  though  less  so  than 
that  which  proceeds  from  villous  growths  of  the  bladder. 

The  renal  characters  of  the  luematuria  are  generally  at  once  evident. 
The  blood  is  generally  more  tawny  or  embrowned  than  when  from  the 
bladder,  and  is  so  uniformly  admixed  with  the  urine  that  each  micturi- 
tion is  bloody  from  first  to  last;  the  latter  portion  perhaps  more  so  than 
the  earlier,  but  not  with  the  accumulation  of  blood  at  the  end  which  be- 
longs to  vesical  hemorrhage.  The  bloody  sediment  is  powdery  and  inco- 
herent. Clots,  if  any  occur,  are  small  and  generally  somewhat  fibrinous- 
or  decolorized  ;  they  may  have  a  slenderly  vermiform  shape  which  they 
have  taken  from  the  ureter,  but  this  is  infrequent.  Bladder-clots  aro 
usually  soft  and  red  as  if  newly  congealed;  they  are  shapeless,  and  often 


i 


CLINICAL    ASPECT    OF    MALIGNANT    TUMORS.  73 

of  such  bulk  tliat  their  escape  by  the  urethra  would  seem  an  impossibility; 
tlioy  are  often  indeed  shot  out  only  after  prolonged  effort.  Renal  hemor- 
rhage, on  tiie  contrary,  though  it  has  been  known  to  cause  obstruction 
of  the  ureters,  and  fatal  supj^ression,  seldom  if  ever  impedes  the  urethral 
exit.  The  hemorrhage,  unlike  that  from  renal  calculus,  is  not  more 
abundant  on  going  to  bed  at  night  than  on  rising  in  the  morning — in- 
deed, the  reverse  is  often  the  case,  as  if  the  discharge  were  favored  by 
the  horizontiil  position;  and  the  distinction  from  the  bleeding  of  stone  is 
further  marked  by  the  almost  invariable  cessation  of  the  latter  after  some 
days  in  bed,  while  that  of  malignant  disease  is  not  much,  if  at  all,  less- 
ened thereby. 

The  urine,  when  not  bloody,  is  usually  perfectly  natural — the  growth 
has  not  broken  into  the  pelvis,  and  the  secretion  is  that  only  of  the 
healthy  glandular  structure.  As  to  the  microscopic  appearances  of  tlie 
urine,  into  which  a  morbid  discharge  has  found  entrance,  it  necessarily 
contains  blood-corpuscles,  usually  in  vast  abundance,  but  never  anything; 
pathognomonic  of  their  source. 

Casts  as  a  rule  are  absent — a  negative  symptom  of  some  importance, 
as  excluding  a  form  of  nephritis  in  which  bleeding  may  be  profuse 
enough  to  suggest  a  growth,  but  with  which  these  evidences  of  disease 
are  many,  dark,  and  striking.  Exceptionally  casts  are  to  be  found. 
These  may  be  the  result  of  renal  disease,  only  accidentally  associated  with 
the  growth,  or  they  may  proceed,  as  may  happen  in  connection  with  many 
localized  renal  changes,  from  tubal  disturbance  in  the  immediate  neighbor- 
hood of  the  growth. 

Pus,  if  present,  is  so  only  as  an  accident.  "Cancer-cells,"  or  nucle- 
ated bodies  which  could  pass  for  them,  are  conspicuously  absent.  With 
bladdei'-cancers  and  villi,  squamous  cells,  exhibiting  every  form  of  morbid 
luxuriance  in  nucleation  and  shape,  are  often  abundantly  found,  and  even 
considerable  masses  of  cellular  growth  are  sometimes  expelled,  within 
which  blood-vessels  can  be  detected. 

The  pelvic  and  vesical  mucous  membrane  may  be  stimulated  to  des- 
quamation by  a  variety  of  circumstances,  some  of  a  transient  nature; 
and  from  one  part  or  another,  cells  of  every  degree  of  rotundity  or  flat- 
ness may  proceed.  But  with  renal  tumors,  such  evidences  of  disease  are 
seldom,  if  ever,  found.  Keviewing  my  own  experience,  I  have  found 
cases  in  plenty  where  large  cellular  deposit  has  been  associated  with 
cancer  of  the  bladder.  I  have  known  several  in  which  the  presence 
of  cancer  in  some  })art  of  the  urinary  tract  has  been  confidently  presumed, 
in  consequence  of  the  abundance  in  the  urine  of  nucleated  and  prolifer- 
ating cells,  and  in  which  the  recovery  of  the  patient  has  negatived  any 
such  supposition.  I  have  met  with  not  a  few  in  which  a  discharge  of 
cells  of  epithelial  type,  together  with  blood,  has  been  supposed  to  indi- 
cate cancer  of  the  kidney,  but  not  with  one  in  which  this  supposition 
has  been  verified.  If  I  am  told  that  such  a  one  is  passing  "  cancer-cells  '" 
in  the  urine,  I  conclude  that,  whatever  his  disease  may  be,  it  is  not  can- 
cer of  the  kidney.  A  deposit  consisting  of  blood-corpuscles,  mixed,  if 
with  anything,  with  indefinite  sanguinolent  material,  and  that  constant, 
during  repose  as  well  as  under  exercise,  is  a  sign  in  this  i-espect  of  more 
meaning.  It  is  to  be  borne  in  mind  that  a  f ungating  tumor  of  the  kid- 
ney is  less  often  cancer  than  sarcoma,  the  cells  of  wiiich,  associated  as 
they  are  with  connective  tissue,  are  not  to  be  easily  and  abundantly  shed, 
while,  even  should  they  reach  the  urine,  they  are  at  least  in  the  small- 


74  CLINICAL    ASPECT    OF    MALIGNANT    TUMORS. 

celled  varieties,  which  are  the  more  numerous,  too  small   to  attract  at- 
tention when  confused  with  red  and  white  blood-corpuscles. 

The  remaining  symptoms  of  the  disease  may  be  termed  accidental; 
they  relate  to  extension  of  the  disease  to  other  organs  than  that  prima- 
rily affected.  That  most  distinctive  of  renal  growths,  whether  cancer- 
ous or  of  the  nature  of  sarcoma,  is  the  spinal  complication.  With  a 
considerable  propoi'tion  of  malignant  renal  growths,  tiie  adjacent  ver- 
tebral surface  is  more  or  less  eroded,  and  tlie  spinal  column  is  sometimes 
cut  througii,  with  evidences  of  spinal  disease,  severe  pain  in  that  situa- 
tion, localized  tenderness,  and  possibly,  as  noted  in  one  instance,  crepi- 
tus, like  that  of  broken  bone,  between  the  adjacent  halves  of  a  severed 
vertebral  body.  With  these  come  the  various  stages  of  paraplegia,  which, 
as  far  as  I  have  seen,  are  apt  to  begin  with  paralysis  of  the  bhidder,  and 
be  evident  tliere  for  a  little  time  before  the  extremities  are  affected. 
Tiie  suffering  which  this  extension  may  involve,  the  pain  of  the  encroach- 
ing growth,  the  paralytic  helplessness,  the  retentiion  of  urine,  the  non- 
retention  of  faeces,  the  deep  and  extending  bed-sore,  is  more  than  is  often 
comjn'ised  in  the  process  of  natural  death. 

Another  result  of  malignant  renal  tumor,  which,  though  indirect  and 
not  peculiar  to  disease  of  this  origin,  has  yet  been  so  striking  in  some 
instances  which  I  have  seen,  as  to  deserve  special  mention,  depends  upon 
the  conveyance  of  the  morbid  process  to  the  lung,  and  takes  the  form 
of  asthmatic  or  laryngeal  dyspnoea.  In  one  instance,  attacks  like  severe 
asthma  occurred,  which  were  unaccompanied  with  stethoscopic  evidence 
of  disease,  completely  intermittent,  and  were  found  after  death  to  have 
been  associated  with  scattered  growths  throughout  the  lungs.  In  another 
case  there  was  severe  dys})noea  on  exertion,  particularly  on  going  up- 
stairs, wdiich  the  patient  referred  to  the  larynx,  together  with  spasmodic 
cough,  like  whooping  cough,  and  the  occasional  raising  of  peculiar  hol- 
low sputa,  around  which  a  cellular  or  corpuscular  growth  was  detected, 
foreign  to  the  proper  structure  of  the  lung,  which  gave  the  only  conclu- 
sive evidence  as  to  the  kind  of  disorder  from  which  the  patient  was  suf- 
fering. 

Cancerous  or  malignant  matter  belonging  to  the  kidney  may  be  dis- 
charged, or  intrude  itself  variously. 

A  child  three  years  of  age,  who  was  in  St.  George's  Hospital  with  a  large 
cncephaloid  (?)  tumor  of  the  left  kidney,  passed  blood  by  the  bowels, 
and  then  after  an  interval  had  much  abdominal  pain,  vomiting,  and 
purging,  under  which  it  sank,  seventeen  days  after  the  discharge  of 
blood.  It  was  found  that  the  descending  colon  and  the  tumor  were 
firmly  connected  by  adhesions,  and  that  in  the  midst  of  the  tumor  was  a 
cavity,  due  to  breaking  down  of  growth,  the  products  of  which  had  es- 
caped into  the  colon  by  an  ulcerated  opening  through  its  walls. 

The  duodenum  has  likewise  been  penetrated  by  a  renal  cancer,  as  in 
an  instance  recorded  by  Kayer,'  in  which  a  portion  of  a  tumor  of  this 
nature,  belonging  to  the  right  kidney,  was  found  to  have  intruded  itself 
through  an  ulcerated  opening  into  the  cavity  of  the  bowel.  Death  had 
been  preceded  by  obstinate  vomiting  and  hiccup. 

Perforation  of  the  abdominal  wall  by  renal  cancer  has  been  recorded 
at  least  in  one  instance:  that  of  a  child,  three  years  old,  mentioned  by^ 
Abele,  in  whom  a  medullary  growth  of  renal  origin  sprouted  artificially. 


•  Maladies  des  Reins,  vol.  iii.  p.  705. 


CLINICAL    ASPECT    OF    MALIGNANT   TUMORS. 


75 


carrying  with  it  a  loop  of  intestine,  which  became  gangrenous,  and  dis- 
charged faeces  superficially. 

The  duration  of  malignant  renal  growths,  most  conveniently  esti- 
mated independently  of  their  division  into  cancers  and  sarcomata,  varies 
with  age.  The  growths  of  childhood  are  softer  and  more  rapid  than 
those  of  later  life;  and,  besides  this,  they  are  more  often  painless,  so  that 
the  apparent  may  be  often  much  out  of  proportion  to  the  real  duration, 
since  there  may  be  no  sign  of  the  disease  until  the  abdominal  tumor  be- 
comes obvious.  It  is  indeed  evident  that  under  most  circumstances  a 
o-rowth  so  deeply  seated,  and  one  that  usually  does  not  seem  to  interfere 
with  the  function  of  the  organ  in  which  it  is  placed,  is  likely  to  remain 
in  obscurity  for  so  mucli  of  its  early  life  that  to  every  statement  of  the 
duration  of  the  disease  an  uncertain  time  must  be  added. 

In  fifteen  of  the  cases  to  which  I  have  referred  from  hospital  and  pri- 
vate records,  the  time  from  the  advent  of  the  first  symptom  to  death  is 
stated  with  distinctness.     This  varied  from  eighteen  days  to  four  years: 

Duration  of  Malignant  Renal  Growths. 


Prom  first  symptom  to  death  under 
6  months 

Prom  first  symptom  to  death  from 
6  months  to  1  year 

Prom    first    symptom    to    death    from 

1  year  to  2  years 

Prom    first    symptom    to    death    from 

2  years  to  3  years 

Prom    first    symptom    to    death  from 

3  years  to  4  years 


Children 

13  months 

to  4  years  old 


Adults 
25  years  to 
58  years  old. 


Total 


Collected  experience  shows  a  similar  distribution.  Of  nineteen  cases 
among  children,  collected  by  Roberts,*  the  mean  duration  was  nearly 
seven  months;  the  minimum  ten  weeks,  the  maximum  over  a  year.  With 
adults  twenty-one  cases  gave  an  average  of  two  and  a  half  years,  the  ex- 
tremes ranging  from  five  months  to  seven  years.  Ebstein'"  gives  the  ap- 
parent duration  in  children  at  from  five  weeks  to  two  years,  in  adults  the 
time  being  variously  extended  to  a  maximum  of  eighteen  years,  for  which 
length  of  time  the  disease  "  was  demonstrated  to  have  lasted"  in  an  in- 
stance in  which  it  took  its  origin  from  a  fall. 

Roberts  observes  justly  on  the  frequently  long  duration  of  renal  "can- 
cer," and  refers  it  in  part  to  the  duplication  of  the  organ;  but  a  more 
fundamental  reason  presents  itself  in  the  fact  that  renal  cancer  of  clinical 
medicine  is  commonly  not  cancer,  but  sarcoma — a  sarcoma  sometimes  of 
exceeding  malignancy,  but  in  other  cases  having  the  hard  structure  and 
slowness  of  extension  which  belongs  to  the  more  sluggish  forms  of  the 
recurrent  fibroid  tumor. 


'  Roberts's  Renal  and  Urinary  Diseases,  2d  Edit.  p.  252. 
'  Ziemssen's  Cyclopcedia,  vol.  xv.  p.  684. 


76 


CLINICAL    ASPECT    OF    MALIGNANT    TUMORS. 


Treatment  of  Malignant  Disease  of  the  Kidney. 

Witli  regard  to  the  treatment  of  renal  growths,  the  first  consideration 
must  be  of  the  feasibility  of  operation  and  cure.  Modern  surgery  lias 
demonstrated  the  possibility  of  the  removal  of  one  kidney  withouta  neces- 
sarily fatal  result.  Malignant  tumor  of  the  kidney  will  surely  kill  if 
left  alone;  with  the  rapid  growth  of  childhood  this  end  is  seldom  long 
delayed  after  the  detection  of  the  growth.  If  excision  could  cure  even  a 
considerable  minority  a  gain  of  life  would  ensue,  even  though  the  death 
of  the  rest  shoiikl  be  hastened.  Looking  first  at  the  question  in  the  light 
of  morbid  anatomy,  I  must  refer  to  page  51,  where  is  a  statement  of  tlie 
frequency  of  malignant  growths  in  otiier  parts  of  the  body  secondarily  to 
those  arising  in  one  kidney — since  I  presume  that  no  surgeon  would  think 
it  right  to  extirpate  the  kidney  were  the  operation  to  leave  progressive 
and  fatal  disease  elsewhere.  It  appears  that  of  nineteen  cases  of  malig- 
nant renal  tumor  which  were  examined  after  death,  which  had  occurred 
in  the  natural  course  of  the  disease,  there  were  but  three  in  which  the 
growth  was  confined  to  one  kidney.  Allowance  must  of  course  be  made 
for  the  fact  that  in  all  these  cases  the  disease  was  permitted,  in  the  ab- 
sence of  operation,  to  extend  to  the  utmost  limits  consistent  with  life. 
It  is  to  be  presumed  that  at  an  earlier  date  the  proportion  of  secondary 
disease  would  have  been  less;  nevertheless  it  is  of  grave  significance. 
Looking  now  at  the  results  of  experiment,  there  have  been  up  to  this 
date  (July,  1882),  as  far  as  I  know,  eleven  instances  in  which  a  kidney, 
the  seat  of  a  malignant  tumor,  has  been  extirpated,  either  by  design  or 
as  the  result  of  an  operation  begun  with  some  other  view.  The  results 
are  briefly — six  deaths  as  the  immediate  results  of  the  operation,  five 
recoveries.'     Thus  it  must  be  allowed  that  excision  of  a  cancerous  kidney 

'  I  subjoin  a  brief  enumeration  of  the  cases  of  excision  to  which  I  have  re- 
ferrei-l,  for  which  I  am  mainly  indebted  to  Mr.  Barker's  tables  in  the  Med.  Chir. 
Trans,  for  1880  and  1881,  and  to  which  I  must  refer  for  further  particulars. 
Among  the  eleven  cases  mentioned  are  four  in  which  the  operation  was  under- 
taken on  erroneous  diagnosis — once  for  a  cj'st  of  the  liver,  once  for  a  tumor  which 
was  thought  to  be  either  splenic  or  ovarian,  once  for  ovarian  tumor,  once  for  renal 
calculus.  The  description  of  the  tumor  removed  is  probably  not  always  to  be 
accepted  as  the  result  of  minute  observation. 

Enumeration    of    Cases    of    Excision    of   Kidney    for    a    Malignant 

'Tumor. 


Operator  and  Date. 

Sex,' 
Age. 

Place  of 
Incision. 

Result.                            Condition  of  Organ. 

Walcot      (America), 

M 



Death  in  15  days,  from  Enceplialoid,  2^  lbs. 

1S61. 

58 

suppuration  and  ex- 

haustion. 

Kocher  (Bern),  April 

F 

Ventral 

Death  on  3d  day,  from 

Extensive      sarcoma 

1876. 

35 

peritonitis.       Opera- 
tion not  completed. 

which  involved  meso- 
colon. 

Heuter  (Greifswald), 

F 

Linea 

Death  under  operation 

Perinephritic  sarcoma, 

July,  1876. 

4 

alba 

from  hgemorrliage. 

5  lbs.  in  weight. 

Jessop  (Leeds),  Jan. 

M 

Lunibar'Temf)orary     recovery. 

Malignant  tumor. 

1877. 

2i 

'     Disease  recurred 

probably   in   lumbar 

glands.     Died  about 

9  months  after  opera- 

tion. 

CLINICAL    ASPECT    OF    MALIGNANT    TUMORS. 


77 


IS  practicable  without  such  inordinate  danger  as  to  put  it  out  of  consid- 
eration. The  question  must  turn  on  the  permanence  of  tlie  cure;  and 
here  our  evidence  is  as  yet  imperfect.  Lossen's  case  recovered  from  the 
operation,  but  we  have  no  fiirthei-  knowledge  of  the  patient.  Martin's 
patient  was  in  good  healih  two  and  a  half  years  afterwards;  Byford's  two 
vears  and  four  months  afterwards.  Jessop's  patient  died  under  a  return 
of  tiie  disease,  within  a  year;  Adams's  patient  in  about  six  weeks;  both 
with  disease  of  the  same  nature,  in  the  lumbar  glands  and  elsewhere. 
Tlius,  in  the  whole  number  we  have  but  two  cases,  or  possibly  three  if  we 
incUide  Lossen's,  in  which  the  ultimate  result  was  favorable.  It  is  clear 
that  both  cancer  and  sarcoma  of  tiie  kidney  are  highly  malignant;  neither 
are  as  a  rule  discoverable  until  they  have  attained  the  bulk  of  palpable 
aljdominal  tumors,  and  reached  therefore  a  comparatively  advanced  stage; 
and  on  the  whole  I  doubt  whether  a  permanent  cure  is  to  l^e  anticipated 
in  a  sufficient  proportion  of  cases  to  justify  the  large  risk  of  immediate 
death  which  the  operation  entails. 

The  palliative  treatment  of  malignant  renal  growths  has  to  be  directed 
for  the  most  part  towards  the  relief  of  pain  and  the  control  of  hasmor- 
rhage.  The  use  of  morphia  by  the  mouth,  or,  better,  by  the  skin,  is  of 
ilie  first  value;  its  systematic  use  will  sometimes  prove  of  the  greatest 
omfort.  A  smaller  measure  of  relief,  with  a  complete  absence  of  any 
injurious  effect,  is  to  be  obtained  from  the  a]iplication  of  plasters  of  opium 
or  belladonna,  or  the  aconite  liniment.  Sometimes  in  connection  with 
renal  or  vesical  growths,  a  burning  sensation  over  the  kidney  or  ureter  is 
a  source  of  distress;  for  this,  as  observed  by  Prout,  an  ice-bag  is  the  best 
remedy.  Hemorrhage,  when  present,  is  usually  the  symptom  which 
most  urgently  seeks  relief.     That  the  bleeding  is  from  a  growth  may  be 


Operator  and  Date. 


Kocher  (Bern),  Dec. 

1877. 

Byford      (America), 
March,  1878. 

Martin  (Berlin),  Dec. 

1878. 


Czerny  (Heidelberg), 
Jan.,  1879. 

Lessen  (Heidelberg), 
Aug.,  1879. 

Barker        (London), 
Dec,  1879. 

Adams  (London), 
March,  1882. 


Sex. 
Age. 

Place  of 
Incision. 

M 

2i 

Ventral 

F 
39 

Linea 
alba. 

F 
53 

Ventral 

M 
50 

Ventral 

F 

37 

Linea 
alba 

F 

21 

Linea 
alba 

M 
30 

In  loin, 
parallel 

with 
last  rib 

Result. 


Death  on  3d  day,  from 
peritonitis. 

Recovered  rapidly.  Pa- 
tient in  good  health, 
July,  1880. 

Complete  recovery. 
Known  to  be  in  good 
health  2|  years  after- 
wards. 

Death  in  10  hours, 
from  shock. 

Recovery  perfect. 
Later  history  not 
known. 

Death  in  45  hours, 
from  pulmonary 
thrombosis. 

Recovered  from  opera- 
tion, but  died  about 
6  weeks  afterwards, 
from  recurrence  of 
disease  in  lumbar 
glands. 


Condition  of  Organ. 


Large  adeno-sarcoma. 


Encephaloid,  4|  lbs. 


Malignant  new  growth 
weighing  28  oz. 


Soft  sjjongy  mass  left  in 
situ. 

Angio-sarcoma  5  times 
size  of  kidn(\v  grew 
fi'om  its  surface. 

Two-thirds  of  organ 
converted  into  en- 
ce])haloid. 

Carcinoma. 


78 


CLINICAL    ASPECT    OF    MALIGNANT   TUMORS. 


more  certain  than  either  the  position  of  the  growth  or  its  nature;  but, 
whether  from  the  kidney  or  bladder,  whether  compact  or  villous,  internal 
astringents  are  often  attended  with  advantage.  Striking  and  speedy  re- 
sults have  indeed  sometimes  ensued  upon  such  remedies,  where,  from  the 
case  having  presented  itself  only  in  its  clinical  phase,  it  has  been 
impossible  to  define  it  with  certainty  further  than  as  one  of  a  bleeding 
growth. 

I  have  seen  the  best  results  from  iron  alum,  tannate  of  alumina,  gallic 
acid,  ergot,  and  the  witch-hazel.  Gallic  acid  and  ergot,  given  together, 
have  been  followed  by  the  complete  arrest  of  profuse  hgemorrhage,  pre- 
sumably of  villous  origin,  while  I  have  often  known  bleeding,  evidently 
from  malignant  disease,  to  be  conspicuously  controlled  by  the  tannate  of 
alumina  or  iron  alum. 


I 


CHAPTER  Till. 

TUBERCLE. 

Pathology. 

Looking  at  tlie  kidney  itself,  and  first  at  the  manifestations  of  dis- 
ease which  are  evident  to  the  naked  eye,  tubercles  and  tubercular  con- 
cretions present  themselves  in  it  of  every  size  and  grade.  These  range 
from  delicate,  scarcely  visible,  gray  tubercles  of  the  finest  miliary  dimen- 
sions, up  to  caseous  and  softening- masses  which  may  be  as  large  as  peas, 

ir  nuts,  or  even  larger  than  to  be  so  comj^ared,  and  which  may  be  sa 
numerous  as  to  present  a  considerable  bulk  in  comparison  witli  what  is 
left  of  the  renal  tissue.  It  is  not  practicable  to  make  any  definite  dis- 
tinction between  the  miliary  and  the  caseous,  the  miliary  become  caseous 
;is  they  enlarge,  so  that,  though  in  some  cases  there  may  be  only  one  or 

Mily  the  other,  yet  they  are  continually  intermixed  and  inseparable,  as 
different  results  of  the  same  process. 

The  growths,  especially  when  miliary,  are  more  often  found  in 
tlie  cortex  than  in  the  cones,  though  often  in  both.  They  are  com- 
monly distributed  apparently  at  random  through  the  cortex,  with  no 
further  bias  than  one  towards  the  surface,  upon  which  they  display 
tiiemselves  in  circular  outline  while  they  push  inwards  in  somewhat 
conical  shape.  Occasionally  it  is  to  be  discerned  that  their  distribution 
IS  determined  by  that  of  some  arterial  branch.  Where  recent,  they 
;tre  often  surrounded  by  zones  of  injection  almost  like  emboli  or 
])V£emic  abscesses.  When  of  larger  bulk,  as  considerable  caseous  masses 
they  may  soften  in  their  centres  and  form  abscesses,  which  may  be 
long  locked  up,  or  may  possibly  escape  by  the  surface  or  through  one 
of  tlie  cones  into  the  pelvis.  But  Avhen  such  discharge  occurs  it  is  more 
often  from  the  deposition  of  tubercle  in  tlie  cones  themselves  than  by 
way  of  exit  to  an  abscess  of  cortical  origin.  T'hus  the  occurrence  of 
tubercle  in  the  pyramids,  though  less  frequent  than  in  the  cortex,  has 
especial  interest  in  relation  to  the  symptoms  of  the  disease.  These  por- 
tions of  the  organ  are  apt  to  display  some  small  tubercular  masses  at 
their  apices  or  to  be  extensively,  or  some  even  completely,  replaced  by 
caseous  tubercle  or  abscesses  of  tubercular  origin.  The  cone  splits  be- 
tween its  converging  lines,  and  the  pus  thus  fiiuls  its  escape  into  tlie  pel- 
vis where  the  manimillary  process  points.  Often  the  opening  is  delayed, 
and  a  considerable  globular  cavity  formed  in  the  place  of  the  cone,  before 
the  narrow  orifice  has  been  formed;  thus  the  vomica  may  have  the  shape 
of  a  flask  or  bottle,  a  rounded  cavity  discharging  by  a  narrow  neck. 
Many  pyramids  may  be  thus  excavated,  and  the  kidney  so  converted  into 
a  mere  cyst,  with  many  septa,  each  septum  or  partition  being  the  con- 
densed remnant  of  the  portion  of  cortex  between  adjacent  cones,  wliile 
the  pelvis  is  the  common  vestibule  with  which  all  the  chambers  commu- 


80 


TUBERCLE. 


nicate.  The  process  may  extend  until  the  outer  cortex  is  so  excavated, 
and  so  mucli  transformed  by  the  concurrent  processes  of  glanduhir  atro- 
phy and  fibrous  increase,  tluit  it  also  may  be  reduced  to  little  more  than 
fibrous  tissue,  and  tlie  whole  organ  to  a  chambered  shell.  The  process  of 
transformation  is  sometimes  aided  by  stoppage  of  the  ureter,  and  accumu- 
lation of  the  renal  contents,  as  a  consequence  of  which  the  organ  may  be 
distended  as  well  as  excavated.     The  organ  may  at  last  shrink,  and  be- 


Tuberculoiis  kidney.  Tubercles,  which  in  manj'  instances  have  be^un  to  soften,  scattered 
throiij<hoiit  cortical  tissue.  Pelvis  and  ureter  much  thickened.  (From  a  drawing  in  St.  George's 
Hospital.) 

come  quiescent,  a  partly  caseous  and  partly  calcareous  mass,  or  possibly 
one  wholly  calcareous,  remaining  imbedded  in  its  fibrous  case.  It  is  to 
be  observed  that  as  this  process  goes  on,  fat  accumulates  ujion  and  about 
the  organ. 

The  foregoing  sketch  has  been  drawn  from  those  cases  only  in  which 
the  tuberculous   nature  of   the  renal  disease   has  been  attested  by  the 


TUBERCLE. 


81 


occurrence  of  tubercle  elsewhere.  Among  them  were  many  in  which  the 
origan  had  been  so  completely  transformed  into  a  bag  of  pus,  or  of  some- 
thing resembling  wet  plaster  of  Paris,  or  chalk,  that  neither  renal  tissue 


Tuberculous  excavation  of  kirlney  with  membranous  pyelitis.    A  separable  false  membrane  Is 
seen  iinmg  tlie  inf  nndibuluui.    (From  a  preparation  at  St.  Thomas's  Hospital.) 

nor  tubercle  remained,  and  it  would  have  been  impossible  but  for  the 
extraneous  testimony  to  make  sure  of  the  tubercular  origin  of  the  dis- 
6 


82 


TUBERCLE. 


order.  Several  cases  of  similar  destruction  of  the  kidney  occurred  with- 
out either  remaining  tubercle  in  the  organ,  or  any  external  to  it,  to 
declare  the  nature  of  the  disease;  it  is  probable  that  many  such  were 
tubercular,  as  indeed  they  were  regarded;  but  since  renal  suppuration  of 
other  origins  may  produce  a  similar  result,  each  such  instance  may  be 
attended  with  doubt. 

Proceeding  with  the  help  of  the  microscope  to  further  detail,  it  was 
found  that  the  gray  miliary  and  the  yellow  caseous  tubercle  differed  in 
size,  distribution,  and  standing  rather  than  in  kind.  To  take  the  small 
miliary  nodules  as  typical  of  the  rest,  these  may  be  first  noticed  as  small 
circumscribed  masses  of  interstitial  growth,  consisting  of  minute,  ill- 
defined  nuclei.  Though  less  definite  in  structure,  this  resembles  in  sit- 
uation the  common  fibrosis  of  the  kidney,  accumulating  around  the 
Malpighian  bodies,  and  swelling  the  reticulum.     These  formations  may 


Acute  general  tuberculosis  of  kidney  in  a  child.    Caseous  mass  in  contact  with  blood-vesseU 
nuclear  growth  around;  few  distended  tubes  on  circumference.    (From  cortex.) 

be  scattered  apparently  at  random  in  the  cortex  without  any  indication 
of  what  determines  their  i)osition.  Tlie  next  stage  is  the  transformation 
of  the  central  part  into  a  yellow  rounded  mass  of  indefinite  structure, 
which  has  lost  all  trace  of  organization,  and  tends  to  crack  or  break  in 
the  centre,  while  it  is  surrounded  by  a  zone  of  the  same  ill-marked  and 
indefinite  fibrosis  as  formerly  constituted  the  wliole.  In  some  instances 
of  recent  and  rapid  growth,  the  injection,  though  less  intense,  is  not 
very  unlike  that  which  suri'ounds  an  abscess.  The  larger  masses,  con- 
nected possibly  with  arterial  branches  of  considerable  size,  may  display 
their  anatomical  relations  with  graphic  distinctness,  one  sometimes  look- 
ing like  a  bead  upon  a  thread,  or,  should  the  section  so  determine,  like  a 
plum  upon  a  stalk. 

The  annexed  woodcut  shows  tlie  yellow  amorphous  mass  in  immediate 
contact  with  the  vessel,  the  nucleated  growth  outside  it  and  around  all 
the  renal  structures,  with  evidence  of  localized  nephritis  in  the  obstructed 


I 


TUBERCLE. 


83 


^-^^;>. 


^V 


(' 


NX., 


condition  of  some  of  the  tubes.  Another  outline  shows  also  the  stalk- 
like arrangement  produced  by  the  section  of  the  vessel  in  the  midst  of 
the  mass.  The  tubal  obstruction  is  not  the  only,  or  even  the  chief,  in- 
fljinimatory  change  which  the  kidney  undergoes  in  consequence  of  the 
tubercular  action:  interstitial  nucleation,  or  fibrosis,  is  often  conspicu- 
ous, not  only  in  the  immediate  neigh- 
borhood of  the  tubercles,  but  also  some- 
what widely  distributed.  Sometimes 
tlie  common  interstitial  nucleation  is 
connected  inseparably  with  the  tuber- 
cular, as  if  they  were  but  different  parts 
of  tlie  same  process. 

The  tubercular  masses,  when  they 
occur  in  the  cones,  are  sometimes  col- 
lected into  wedge-shaped  groups  lilvc  the 
iisposition  of  emboli  or  pysemic  ab- 
^nesses,  and  the  resemblance  may  be  in- 
ci-eased  by  a  circumference  of  vascular 
injection. 

In  one  instance  which  came  under 
my  observation,  the  minute  anatomy 
])roper  to  tubercle  was  remarkably  inter- 
mixed with  that  of  a  large-celled  growth. 
The  kidney  to  the  naked  eye  had  ordi- 
nary tubercular  characters.  There  were 
several  collections  of  half-caseous  pus 
in  the  cortex,  which  were  regarded  as 
suppurating  tubercle  ;  and  their  tuber- 
cular character  was  confirmed  by  the 
presence  of  an  apparently  tuberculous 
ulcer  in  the  bladder,  and  an  abundance 
■)i  miliary  tubercles  in  the  lungs.  Under 
tlie  microscope  the  kidneys  displayed  in 
parts  the  nuclear  and  caseating  appearances  which  usually  belong  to 
tubercle,  but  in  other  parts  were  aggregations  of  very  large  nucleated 


Mass  of  tubercle  upon  an  artery  cut 
diagonally  so  as  to  give  stalk-like  appear- 
ance. Amorphous  matter  next  vessel, 
nuclear  growth  outside.  (From  cortex  of 
kidney  of  same  subject  as  preceding.) 


lArgfi  cells  within  a  fibrous  reticulum  from  a  kidney  which  to  the  naked  eye  was  tubercular. 
(From  a  woman  whose  case  is  also  referred  to  in  woodcut  at  p.  90.) 


cells  lying  together  like  the  cells  of  cancer  or  of  an  alveolar  sarcoma.  In 
some  places  were  fibrous  bars  or  partitions,  which  divided  groups  of  cells 
in  mutual  contact;  elsewhere  — and  this  was  most  stritcing,  as  forming 
the  lining  of  one  of  the  considerable  abscesses — these  cells  were  heaped 


84 


TUBERCLE. 


together  without  any  further  evidence  of  reticulum  than  a  few  ragged 
shreds  protruding  from  the  edge.  If  we  regard  this  as  a  concurrence  of 
two  growths,  as  tiie  mixed  characters  would  suggest,  we  have  to  observe 
that  tlie  sarcoma  broke  down  with  suppuration,  certainly  not  a  habit 
with  tliat  growth.  On  the  other  hand,  if  the  large  cells  were  tubercular, 
they  were  at  least  exceptional  in  that  relation. 

Tlie  disintegration  and  excavation  of  the  tubercular  masses  is  an  im- 
portant step  in  the  destructive  process.  These,  having  attained  a  certain 
size,  break  down  in  their  centres  and  form  cavities  which,  so  long  as  they 
are  confined  to  the  cortex,  are  more  or  less  circular;  but  on  reacliing  the 
cones  tiiey  are  apt  to  elongate  in  pyriform  shape  with  the  narrow  end 
toward  the  pelvic  cavity,  into  which  they  eventually  discharge.  A  cavity 
in  the  lung  empties  itself  by  a  broncluis;  a  cavity  in  the  kidney  should 
by  analogy  relieve  itself  through  a  renal  tube,  or  a  channel  formed  out 


■mm 


Trom  same  case  as  precedintf 
woodcut.  Section  of  the  wall  of 
tuberculous  (?)  cavity.  The  lar^e 
cells  above  form  the  wall  of  the 
cavity;  the  smaller  below  are  in 
coatact  with  the  renal  structure. 


Section  of  the  pelvic  membrane  of  a  tuber- 
culous kidney,  showinjr  profuse  nucleation 
underneath  the  epithelium. 


of  one.  But,  as  far  as  I  have  been  able  to  observe,  this  is  not  the  case. 
Collections  of  debris,  somewhat,  but  not  much,  larger  than  the  sections 
of  tubes,  are  sometimes  seen  to  be  surrounded  with  a  membrane  which 
might  pass  for  the  wall  of  a  tube,  but  I  have  never  been  able  to  discern 
an  epithelial  lining  upon  it,  or  to  satisfy  myself  that  such  apj^arently 
tubercular  cavities  were  really  of  tubal  origin.  Enlarged  and  obstructed 
tubes  are  sometimes  seen  in  the  neighborhood  of  tubercular  excavations, 
but  1  have  never  been  able  to  trace  a  continuity  between  them.  Thus  it 
would  api^ear  that  the  renal  vomicae  find  exit  otherwise  than  by  the  reiuil 
ducts. 

It  has  been  said  that  the  cavities,  which  are  more  or  less  round  in  the 
cortex,  tend  to  become  elongated  should  they  touch  the  cones.  In  the 
cones  the  whole  structure  is  disposed  in  nearly  parallel  lines,  between 
which  ic  tends  to  yield  under  encruacliment  like  wood  before  the  wedge. 


TUBERCLE.  85 

The  lines  of  cleavage  converge  upon  the  apices  of  the  pyramids,  and  it  is 
here  or  hereabout,  often  by  a  constricted  channel,  that  the  renal  vomica 
finds  its  exit.  When  it  happens,  as  it  often  does,  that  the  growth  of 
tubercle  begins  in  the  cone,  its  discharge  into  the  pelvis  is  of  course  the 
more  ready.  The  mucous  membrane  of  the  pelvis,  ureter,  and  bladder 
may  be  affected  by  tubercular  disease,  together  with  the  kidney,  either 
independently  or  consequently.  When  the  kidney  has  been  excavated  so 
as  to  discharge,  as  it  usually  does,  into  the  pelvis/the  mucous  membranes 
in  the  line  of  exit  are  so  constantly  affected  that  concurrent  evidence  of 
cystitis  is  of  the  first  importance  in  leading  to  the  diagnosis  of  tubercular 
disease. 

The  pelvis  of  the  kidney  in  such  circumstances  is  commonly  injected^ 
inflamed,  thickened,  even  into  a  stiff  caseous  layer,  or  variously  ulcei"- 
ated.  It  sometimes  presents  considerable  tubercular  bosses,  it  is  some^ 
times  sprinkled  with  miliary  tubercle,  while  in  some  cases  a  definite 
nuclear  layer,  apparently  of  a  tubercular  nature,  may  be  traced  in  the 
submucous  tissue. 

It  is  to  be  noted  sometimes  that  a  distinct  layer  of  false  membrane 
will  line  the  pelvic  interior  almost  like  that  of  diphtiieria.  (See  woodcut 
at  p.  81.)  The  connected  ureter  shares  in  the  same  changes;  it  be- 
comes thickened,  ulcerated,  and  transformed  into,  or  occupied  by,  case- 
ous material,  often  so  as  to  lead  to  its  complete  and  permanent  closure,, 
while  the  same  result  is  in  some  cases  attained  by  the  protrusion  into  the- 
channel  of  tuberculous  nodules  or  bosses. 

The  bladder  commonly  participates,  more  especially  near  the  entrance 
of  the  nreter  which  leads  from  the  affected,  kidney,  if  there  be  but  one 
involved,  and  in  other  j^arts,  perhaps  particularly,  at  least  I  have  seen  it 
so  in  several  instances,  about  the  exit  of  the  urethra.  The  membrane 
often  displays  tubercular  nodules  and  isolated  or  diffused,  ulcerations. 
The  arrangement  of  such  localizations  in  the  line  of  the  discharge  is 
often  suggestive  of  their  dependence  on  its  irritative  or  infective  contact. 
It  may  indeed  be  inferred  that  tubercular  disease  of  the  ureter  or  bladder 
is  commonly  secondary  to,  and  produced  by,  that  of  the  kidney,  from 
the  circumstance  that  tubercular  disease  of  the  kidney  is  seldom  asso- 
ciated with  a  similar  condition  of  these  cavities,  unless  the  disorder  in 
the  glands  have  proceeded  to  ulceration  and  discharge.  Among  the 
cases  I  have  referred  to  were  thirty-four  of  excavation  of  the  kidney,  the 
tubercular  character  of  which  was  testified  to  by  tubercle  in  other  oi'gans. 
Among  these,  disease  of  the  bladder  or  ureter  was  recorded  in  twenty- 
three  instances,  and  would  probably  have  been  found  even  more  ofteni 
had  the  examinations  been  conducted  with  this  question  in  view.  Among 
thirty-eiglit  instances  of  non-ulcerated  renal  tubercle  these  cavities  were 
noted  as  diseased  in  but  one  example. 

It  is  undoubtedly  i)ossible,  though  perhaps  not  very  common,  for  the 
bladder  to  become  tuberculous  while  the  kidney  is  not  so;  but  such  is 
the  tendency  of  tubercular  suppuration  of  the  kidney  to  produce  disease 
of  tlie  same  nature  in  the  bladder  that  the  absence  of  vesical  symptoms 
in  i)resence  of  a  purulent  discliarge  from  the  kidney  would  indicate,  with 
little  chance  of  error,  that  the  source  of  the  jnis  is  not  tubercuhir. 

The  kidneys  may  participate  in  a  general  or  scattered  tuberculosis, 
or  may  suffer  alone.  The  former  is  by  far  the  more  common,  insomuch 
that,  of  ninety-five  cases  examined  after  death,  there  were  but  eleven  in 
which  the  disease  was  limited  to  one  or  both  of  these  organs.  Of  all 
but  one  of  these  the  subjects  were  adults. 


86  TUBERCLE. 

It  might  be  supposed  that,  where  the  kidney  only  is  affected,  the  disease 
would  reach  in  this  organ  a  stage  of  furtlier  destructiveness  than  when 
it  is  liable  to  be  cut  short  by  similar  changes  elsewhere;  but,  however 
this  may  be,  among  the  cases  recorded  were  numerous  instances  of  almost 
total  destruction  of  the  kidney  by  tubercular  disease,  in  which  other  or- 
gans shared. 

Among  the  ninety-five  cases  referred  to,  there  were  forty-eight  in 
which  the  disease  had  progressed  to  extensive  excavation:  in  forty-one 
of  these,  tubercles  were  found  elsewhere  than  the  kidneys,  in  seven  not. 
These  facts  lend  little  su])port  to  the  views  which  have  recently  been 
ini])orted,  according  to  which  caseation  is  in  a  considerable  proportion 
of  cases  in-dependent  of  tubercle.  In  the  cases  before  us,  it  was  declared, 
by  the  ])resence  of  widely  scattered  tuberculosis,  that  the  "consumption 
of  tlie  kidney"  was,  in  a  large  proportion  of  cases,  associated  with  unmis- 
takable tubercle. 

Among  eighty-four  cases  of  tubercular  disease  of  the  kidney  associ- 
nted  with  tubercle  in  other  organs  (sixty-one  from  St.  George's  Hospital, 
twenty-three  from  the  Hospital  for  Sick  Children)  were  fifty-nine  in 
which  pulmonary  tuberculosis  existed,  not  including  those  in  which 
the  lungs  took  part  in  acute  general  tuberculosis.  Among  these  were 
thirty-four  instances  of  extensive  pulmonary  phthisis,  eighteen  in  which 
the  chronic  tubercle  was  generally  distributed,  seven  in  which  the  lungs 
contained  tubercular  cicatrices  or  tubercle  in  small  amount.  Including 
the  cases  in  which  the  lungs  were  involved  as  part  of  acute  tuberculosis  or 
tubercular  meningitis,  at  least  two-thirds  of  the  number  were  the  subjects 
of  ])almonary  tubercle — a  fact  of  much  diagnostic  importance.  Next  to 
pulmonary  tubercle  in  order  of  frequency  came  tubercular  meningitis, 
which  occurred  in  seventeen  instances.  It  is  worth  remarking  that,  of 
four  of  these,  the  subjects  were  over  twenty  years  of  age,  in  three  over  forty 
years  of  age,  so  that,  in  this,  as  in  other  associations,  tubercular  meningitis 
presents  itself  as  by  no  means  limited  to  childhood.  In  five  of  the  in- 
stances of  renal  disease  under  discussion,  acute  tuberculosis  occurred 
without  meningitis.  Peritoneal  tubercle,  or  tubercle  of  the  abdominal 
glands,  occurred  in  eight  cases,  tubercle  of  the  supra-renal  capsule  in 
two,  of  the  prostate  in  one,  of  the  ovary  in  one. 

Caries  of  bone  was  found  in  sixteen  cases. 

Roberts'  observes  on  the  comparative  frequency  of  tubercular  disease 
of  certain  of  the  male  organs  of  reproduction,  the  prostate,  the  vesi- 
culge  seminales,  and  testicles,  while  with  the  female  the  generative  or- 
gans have  little  tendency  to  be  implicated.  The  clue  to  the  local  dis- 
tribution of  tubercular  disease  in  cases  of  excavation  of  the  kidney  of 
this  nature  is  to  be  found  in  the  tendency  of  tubercular  discharges  to 
produce  disease  by  their  contact:  thus  the  pelvis,  ureter,  bladder,  and 
possibly  the  prostate  and  urethra,  are  apt  to  be  involved.  Nothing  of 
the  sort  happens  with  cancer  or  other  malignant  disease  of  the  kidney, 
vvliich,  however  generally  it  may  be  disseminated,  has  no  tendency  to  in- 
volve the  outward  passages.  Apart  from  communication  by  discharge, 
organs  other  than  the  kidney  become  involved  much  according  to  their 
general  proclivity,  the  lungs  taking  the  lead. 

Both  kidneys  are  affected  together  in  about  as  many  instances  as 
one  separately.  If  only  one  be  affected,  it  is  more  often  the  right  than 
the  left,  though  in  childhood  this  difference  is  not  apparent.     Of  ninety- 

>  Roberts,  2d  edit.  p.  547. 


TUBERCLE. 


87 


five  cases,  both  kidneys  were  affected  in  forty-seven,  one  only  in  forty- 
€ight.  Taking  childhood,  apart  from  other  periods  of  life,  of  twenty- 
eight  cases  of  which  the  subjects  were  under  twelve  years  of  age,  both 
kidneys  were  concerned  in  nineteen  instances;  one  only  in  nine — the  right 
in  five,  the  left  in  four.  Of  sixty-seven  cases  in  persons  over  twelve 
years  of  age,  both  kidneys  were  affected  in  twenty-eight;  the  disease  was 
limited  to  the  right  in  twenty-two,  to  the  left  in  seventeen. 

The  accompanying  table,  compiled  from  the  2^ost-moi'tem  books  of 
St.  George's  Hospital  and  the  Hospital  for  Sick  Children,  shows  the  fre- 
quency of  renal  tubercle  in  childhood  and  afterwards  in  persons  dead 
from  all  causes.  Considering  liow  rarely  consequences  attributable  to  re- 
nal tubercle  are  detected  during  life,  it  might  not  have  been  anticipated 
that  this  formation  is  to  be  found  on  an  average  in  about  a  tenth  of  all 
who  die — in  children  in  nearly  a  sixth. 

Tubercle  is  especially  a  disease  of  early  life,  as  the  table  shows;  but 
the  proclivity  of  the  disease  in  this  respect  is  more  strongly  displayed  in 
regard  to  the  brain,  the  abdominal  structures,  and  the  kidneys  than 
with  regard  to  the  lungs.  Renal  tubercle  is  nearly  three  times  more  fre- 
quent under  than  over  the  age  of  twelve. 

Table  slioiuing  the  frequency  of  tubercular  formations  in  the  kidney,  and 
other  organs,  in  600  jjost-ninrtem  examinations;  the  subjects  of  300 
being  under  the  age  of  13  years,  the  subjects  of  the  other  300  being 
of  the  age  of  12  years  and  iqnuards. 


Tubercle  present  in  some  part  of  the 
body, in 

Tubercle  in  lungs,  in 

Tubercle  in  peritoneum  or  mesen- 
teric glands,  or  tubercular  dis- 
ease of  bowel,  in 

Tubercle  in  brain  or  its  membranes, 
in 

Tubercle  in  kidney,  in 


s  S^  o 


126 
104 


97 

63 
49 


54 

51 


22 

9 

17 


o.S  ^ 
"3  £  o 


O  i.  c  e3 

S|.2  = 


180 
155 


119 

72 
66 


Clinical  History  and  Symptoms. 

Tubercular  disease  of  the  kidney  during  childhood  affects  the  sexes 
with  impartiality ;  in  later  life  it  attacks  the  male  more  often  than  the 
female.  Of  twenty-eight  hospital  cases  wliich  occurred  under  the  age  of 
twelve,  fourteen  affected  male  and  fourteen  female  subjects.  Of  sixty- 
seven  cases  over  this  age,  forty-four  related  to  males,  twenty-three  t@  fe- 
males— a  proportion  of  nearly  two  to  one. 

So  far  as  we  may  trust  the  experience  of  a  general  hospital,  at  which 
cases  of  every  kind  and  of  all  ages  are  admitted,  tubercular  disease  of  the 
kidney  is  most  frequent  between  twenty  and  forty,  rare  after  fifty.  That 
it  is  common  at  all  the  epochs  of  cliildhood  the  records  of  the  Hospital  for 


88  TUBERCLE. 

Sick  Children  abundantly  show.  It  occurs  in  early  life  as  part  of  acute 
tuberculosis  and  in  association  with  tubercular  meningitis,  and  tlierefore 
presents  itself  with  frequency  under  the  age  of  four,  when  these  condi- 
tions are  most  common.  In  such  circumstances,  and  indeed  more  often 
tiian  not  at  every  time  of  life,  renal  tuberculosis  occurs  merely  as  a  small 
part  of  a  scattered  disease,  with  the  incidence  of  which  its  distribution 
corresponds;  while  it  may  be  added,  that  in  such  circumstances  its 
presence  is  seldom  declared  by  any  symptoms  which  are  recognized  as. 
renal. 

Age  at  Death  with  Tuheixular  Disease  of  the  Kidney. 
St.  George's  Hospital— 70  Cases. 

Number  fatal 
at 
Age  in  years.  stated  age. 

Ito'lO, 4 

11  ••  20, 13 

21  '•  30, 18 

31  "  40, 20 

41  "  50 11 

51  "  60 1 

61  "  70, 2 

71  "  80, 1 

Hospital  for  Sick  Children — 24  Cases. 

Number  fatal 
at 
Age  in  years.  stated  age. 

Under  2  years  old, 3 

2  years  old  and  under  3, 4 

3  ^'  "            "4, 3 

4  "  '•            "0, 3 

5  ••  "            "6 1 

6  "  "            "7, 3 

7  "  "            "8 0 

8  "  "            "9, 3 

9  "  "            "10 3 

10  "  "  "11, 0 

11  "  "  "12 1 

The  most  frequent  causes  of  renal  tubercle  are  those  of  tuberculosis 
in  general,  among  which  inherited  proclivity  takes  the  first  place.  Caries 
of  bone,  as  with  tubercle  in  general,  is  often  noted  as  an  antecedent. 
Measles,  so  often  to  be  recognized  as  incentive  of  tuberculosis,  is  occasionally 
followed  by  tubercle  thus  localized.  This  occurred  in  two  of  the  cases  I 
have  referred  to  from  the  Hos})ital  for  Sick  Children.  Lastly,  as  giving 
rise  to  the  disease  primarily  and  chiefly  localized  in  the  kidney,  blows 
and  falls  upon  the  lumbar  region  are  conspicuous.  Among  the  cases 
to  which  I  have  referred  were  three  in  which  tlie  injury  was  so  directly 
followed  by  the  symptoms  of  the  disease  that  there  could  be  no  hesitation 
in  regarding  them  as  cause  and  effect.  A  man  was  knocked  down  by  a 
cart  and  injured  in  the  right  lumbar  region.  This  remained  persistently 
painful.  Four  years  afterwards  the  rigiit  kidney  was  found  to  be  exten- 
sively excavated,  and  the  pelvis  and  ureter  thickened;  the  lungs  contained 
scattered  tubercle  but  no  vomicae.  A  man  iiad  a  fall  u])on  his  back, 
which  was  followed  by  symptoms  of  psoas  abscess,  with  which  he  died 
three  years  afterwards.  Tiie  psoas  abscess  was  found  to  be  connected,  as 
was  expected,  with  disease  of  the  spine;  but,  in  addition,  both  kidneys 
were  stuffed   with  softening  tubercle,  and  the  pelvis,  left  ureter,  and 


I 


TUBERCLE.  89' 

bladder  ulcerated.  In  the  last  case  a  man  hurt  his  back,  and  for  some 
time  afterwards  passed  bloody  urine.  He  died  in  three  months,  after  an 
epileptiform  attack,  apparently  uremic .  Both  kidneys  were  full  of  tu- 
bercle, miliary  in  the  right,  caseous  and  suppurating  in  the  left.  Miliary 
tubercle  was  also  found  in  the  lungs.  Cold  has  been  assigned  as  a  cause 
of  renal  tuberculosis,  but  my  cases  give  no  instance  of  this  association. 

The  symptoms  are  those  of  sup}nu-ative  pyelitis,  usually  with  an  ele- 
vated night  temperature  and  vesical  irritation.  The  constitutional  signs 
of  tuberculosis,  chronic  fever  and  wasting,  are  commonly  present,  while 
the  subject  is  often  of  scrofulous  appearance  or  antecedents. 

There  is  sometimes  pain  in  the  loins  and  occasionally  down  the  ureter, 
though  less  sharp  in  either  situation  than  may  be  produced  by  stone. 
The  bladder-symptoms  are  possibly  so  urgent  as  to  raise  a  suspicion  of 
calculus:  there  may  be  much  discomfort  referred  to  the  position  of  the 
bladder  or  to  the  penis,  while  micturition  is  frequent,  even  hourly,  and 
sometimes  difficult  ;  there  is,  however,  this  distinction  from  stone — 
when  the  bladder  is  empty  relief  is  complete.  The  patient  is  usually 
sounded,  and  only  a  little  roughening  detected.  Another  distinction 
from  stone  is  to  be  found  in  the  Continuance  of  the  purulent  discharge 
with  the  urine;  when  from  stone  the  discharge  is  apt  to  stop,  often  for 
months,  and  tlien  recur;  if  from  tubercle,  the  first  complete  stoppage 
is  final,  as  it  is  due  to  the  occlusion  of  the  ureter  from  extension  of  the 
disease,  or  to  the  consumption  of  the  tubercular  growth. 

The  constitutional  symptoms  are  more  tuberculous  than  renal,  unless, 
as  is  no  infrequent  complication,  lardaceous  disease  be  superadded. 
Among  ninety-five  hospital  cases  to  which  I  have  before  referred,  in  some 
of  which  it  must  be  allowed  that  the  disease  had  not  advanced  so  far  in 
the  kidney  as  elsewhere,  convulsions  and  coma  were  recorded  as  the  direct 
result  of  renal  tuberculosis  only  in  three  instances;  less  often  than  in  this 
series  of  renal  cases  similar  symptoms  occurred  as  tlie  result  of  the  partici- 
pation of  the  brain  m  the  disease,  in  the  shape  of  tubercular  meningitis. 
It  is  strange  that  uncomplicated  tuberculosis  should  so  seldom  cause 
either  uraemia  or  suppression,  consklering  how  frequently  both  kidneys 
are  involved  in  the  disease.  The  symptoms  are  mostly  those  of  exhaus- 
tion, as  a  result  of  the  discharge,  together  possibly  with  the  effects  of  the 
advance  of  tubercular  disease  in  some  other  organ.  The  patient  under- 
goes slow  wasting,  much  as  if  the  consumption  were  of  the  lung  instead 
of  the  kidney — too  often  it  is  of  both,  as  the  foregoing  statements  sliow 
— has  evening  fever  and  night-sweats,  and  often  lapses  into  fatal  prostra- 
tion, with  a  dry  tongue  and  a  typhoid  aspect.  An  important  ]ioint  in  the 
diagnosis  of  renal  as  of  other  tubercle  is  the  temperature.  In  the  case 
referred  to  on  page  810,  the  morning  and  evening  records  were  generally 
98°  and  103°,  frequently  97°  and  103°,  giving  a  nightly  rise  of  from  4° 
to  6°.  In  many  other  instances  the  temperature  was  that  proper  to  gen- 
eral or  pulmonary  tuberculosis. 

It  is  comparatively  rare  for  tubercular  disease  of  the  kidney  to  pro- 
duce ])alpablo  tumor,  but  I  have  met  with  two  instances  in  wliich  this 
occurred,  and  to  a  sufficiently  noticeable  extent.  In  both,  the  right  kid- 
ney was  the  one  to  which  the  tumor  belonged,  and  the  hypochon- 
di-ium  the  place  in  Avliich  it  became  evident.  The  outlines  of  the  swell- 
ing in  each  case  are  represented  in  the  annexed  woodcuts;  its  renal 
character  in  each  was  clearly  declared  during  life.  In  one  case,  that  of 
a  woman  named  Ann  Evans,  sixty-one  years  of  age,  the  tumor  was  felt 
extending  from  the  edge  of  the  ribs  to  the  level  of  the  umbilicus:  the 


90 


TUBERCLE. 


inner  part  was  overlaid  by  bowel,  the  outer  Avas  immediately  beneath  the 
abdominal  wall;  tlie  mass  could  be  felt  deep  in  the  lumbar  depression. 
After  death  the  right  kidney  was  found  to  be  enlarged  by  tubercular 


Tuberculous  kidney  as  felt  during  life;  be- 
tween the  outer  and  the  dotted  line  the 
tumor  was  overlaid  by  bowel. 


Tuberculous  kidney  as  exposed 
after  death,  showing  its  relation  to 
colon  and  duodenum.  K,  Diseased 
kidney ;  L,  Liver. 


disease,  but  appeared  less  prominent  than  it  had  done  during  life.  It 
had  the  ascending  colon  immediately  in  front;  the  duodenum  was  closely 
,a,dherent  to  its  inner  edge,  where  Avas  a  tubercular  abscess,  the  outer  wall 


Tuberculous  kidney,  wliicli  had  been 
tapped  in  the  belief  lluit  the  tumor 
was  hepatic.  As  felt  during  life.  The 
place  of  the  ptmcture  i.-;  indicated.  The 
tumor  was  superficial  outside  the  faint 
vertical  line,  very  deep  inside  the 
stronger  vertical  line. 


Tuberculous  kidney,  as  shown  after  death 
(from  same  case  as  preceding).  The  upper 
part  of  the  tumor  was  uncovered  by  bowel. 


■of  which  consisted  of  this  ])ortion  of  the  bowel.  In  the  second  instance, 
the  morbid  features  were  almost  the  same.  A  mass  lay  in  the  right  hy- 
pochondrium,  reaching  from  the  edge  of  tbe  thorax  to  three  inches  down- 
wards in  tlie  nipple  line.     I'lie  mass,  which  Avas  on  its  inner  part  covered 


TUBERCLE.  91 

by  bowel,  could  be  traced  under  the  abdominal  wall,  round  the  side,  to 
the  lumbar  region.  The  patient  came  into  the  hospital  as  having  an  ab- 
scess of  the  liver,  and  a  depressed  cicatrix  was  pointed  out  as  the  place  of 
its  puncture  some  five  years  before.  But  though  in  contact  with  the 
liver,  the  mass  was  unequivocally  renal.  There  was  no  depression  of  the 
liver  edge,  or  indication  of  increase  of  size  in  this  organ,  while,  on  the 
other  hand,  the  mass  could  be  traced  into  the  lumbar  region  and  grasped 
in  this  situation  between  the  hands.  Post  mortem,  the  right  kidney  was 
exposed  to  view  below  the  liver  as  soon  as  the  integuments  were  put  aside 
— across  the  lower  part  lay  the  beginning  of  the  colon.  The  duodenum, 
as  in  the  preceding  case,  was  in  contact  with  its  inner  edge.  The  kidney, 
little  changed  in  shape,  though  much  in  size,  measured  six  inches  in 
length,  extending  from  the  last  dorsal  to  the  last  lumbar  vertebra. 

When  the  kidney  excavates,  and  the  process  is  not  cut  short  by  dis- 
ease elsewhere,  the  symptoms  are  so  often  complicated  with  those  of  lar- 
daceous  disease,  that  these  may  be  regarded  as  almost  necessary  to  the 
later  stages  of  the  complaint.  The  urine  becomes  pale,  it  displays  more 
albumin  than  the  pus  could  account  for,  the  legs  become  dropsical,  and 
the  patient  sinks,  with  vomiting  and  diarrhoea,  or,  as  I  have  seen  in 
more  than  one  instance,  dies  with  the  ordinary  signs  of  cerebral  urae- 
mia. 

Among  the  accidents  which  occur  in  the  course  of  the  disease  are  ir- 
regular modes  of  exit  for  the  matter  developed  within  the  kidney;  when 
this  is  of  tuberculous  origin  it  far  less  often  escapes  otherwise  than  by 
the  ureter  than  when  dependent  on  stone,  but  it  does  so  sometimes. 
Among  the  cases  from  St.  George's  Hospital  to  which  I  have  referred, 
is  one  in  which  the  front  of  a  tuberculous  right  kidney  presented  a 
sloughy  aperture  which  communicated  with  a  large  abscess,  which  lay 
behind  the  peritoneum  in  the  lumbar  region,  between  the  kidney  and  the 
ascending  colon  and  the  duodenum.  In  another  instance,  a  hole  simi- 
larly formed  in  the  left  kidney  had  given  rise  to  an  abscess  circumscribed 
by  adhesions  within  the  peritoneal  cavity.  A  third  case  was  a  somewhat 
remarkable  example  of  a  psoas  abscess  of  renal  origin.  A  young  man 
had  a  psoas  abscess  which  discharged  in  the  usual  situation  for  a  year, 
and  of  which  he  died  without  any  suspicion  that  the  abscess  Avas  not 
spinal.  It  proved  to  have  its  source  in  the  left  kidney,  which  was  ex- 
tensively excavated  by  tuberculous  disease;  but  strange  to  say,  there  was 
also  found,  though  upon  the  other  side,  an  incipient  psoas  abscess,  con- 
nected, as  is  usual,  with  diseased  vertebrae.  This  had  penetrated  about 
two  inches  into  the  muscle. 

The  urine  usually  shows  traces  of  albumin  even  before  the  tubercle 
has  proceeded  to  softening.  I  have  l)efore  me  records  of  the  state  of  the 
urine  in  six  cases  in  which  the  kidneys  were  found  after  death  to  contain 
unsoftened  tubercle;  in  four  albumin  was  detected;  in  one  a  little  blood 
as  well.  There  are  as  yet  no  other  changes,  but  as  soon  as  the  organ  be- 
gins to  excavate,  pus  appears,  tliough  it  is  seldom  so  'Maudable,"  not  so 
sharp  in  microscopic  outline,  nor  separating  so  cleanly  from  tiie  super- 
natant urine  as  when  pyelitis  is  the  result  of  stone.  Blood  is  observable 
in  a  minority  of  cases,  it  is  seldom  in  large  amount.  In  the  course  of 
thirty-nine  cases  from  St.  George's  and  the  Hospital  for  Sick  Children  in 
which  the  state  of  the  urine  is  recorded,  hgematuria  was  noticed  in  nine. 
In  three  of  these  it  was  connected  with  much  disease  of  the  bladder,  and 
})resumably  of  vesical  origin.  In  one  it  was  associated  with  marked  lar- 
daceous  disease.     In  the  remaining  cases  the  discharge  of  blood  was  ap- 


92  TUBERCLE. 

parently  dependent  on  the  tuberculous  condition  of  the  kidney  or  its 
outlet.  In  no  instance  was  the  discharge  profuse,  though  it  was  in  some 
obstinate,  especially  where  connected  with  vesical  disease.  As  the  dis- 
ease progresses,  the  urine  is  apt  to  become  ammoniacal  and  variously 
putrid  and  offensive,  to  be  mingled  with  ropy  mucus,  and  to  deposit 
triple  phosphate,  often  as  the  results  of  vesical  disease;  but  it  may  be  al- 
kaline and  even  ammoniacal  in  consequence  of  disease  limited  to  the  kid- 
neys. Both  may  be  so  much  damaged  that  only  plain  alkaline  urine  of 
low  specific  gravity  is  secreted,  and  this  may  become  more  or  less  decom- 
posed by  partial  retention  in  the  pelvis,  and  thus  be  passed  ammoniacal, 
as  in  a  case  recently  under  my  care,  even  though  there  be  no  such  bladder 
disease  as  to  account  for  the  alteration  within  this  cavity.  Often  with 
the  advance  of  the  disorder  the  urine  becomes  highly  albuminous,  and 
displays  hyaline  casts  as  the  consequence  of  the  superaddition  of  larda- 
ceous  change,  by  which  the  secretion  of  the  hitherto  unaffected  kidney 
becomes  modified.  The  occasional  impoverishment  of  the  urine,  with  a 
specific  gravity  as  low  perhaps  as  1.006,  is  occasionally  a  marked  result  of 
double  tuberculous  disease  of  the  kidney,  even  though  there  be  no  larda- 
ceons  change,  or  this  be  only  inciiMent  and  trifling. 

The  time  that  elapses  between  the  commencement  and  the  close  of 
renal  tuberculosis  is  difficult  to  limit;  many  cases  are  cut  short  by  pul- 
monary phthisis,  and  many  by  meningitis;  taking  those  in  which  the  be- 
ginning has  been  marked  and  the  end  mainly  renal,  it  would  seem  that 
the  range  extends  from  about  four  months  to  as  many  years. 

In  those  instances  in  which  the  outset  was  marked,  and  apparently 
occasioned  by  a  blow  or  fall,  the  duration  of  the  disease  was  respectively 
four  months,  three  years,  and  four  years.  A  renal  psoas  abscess  was  open 
for  a  year  before  death;  an  abscess  of  the  same  origin  in  another  case 
which  discharged  from  the  thigh  was  open  also  for  a  year;  the  organic 
disease  necessarily  of  longer  date.  In  three  instances  in  which  the  pres- 
ence of  the  disease  was  declared  only  by  the  more  ordinary  symptoms, 
these  were  noted  for  periods  before  death  of  seven  weeks,  eight  months, 
and  four  years  respectively.  In  the  case  with  the  briefest  reconl,  how- 
ever, one  kidney  was  reduced  to  a  mere  shell,  so  that  the  disorder  had 
existed  for  a  much  longer  time  than  the  symptoms  appear  to  have  been 
observed. 

Instances  are  met  with  in  which  one  kidney  has  been  destroyed  by 
suppuration  apparently  tubercular,  and  the  disease  has  been  limited,  has 
become  quiescent  and  practically  harmless.  Some  of  tliese  cases,  how- 
ever, are  of  doubtful  nature;  the  absence  of  tubercle  elsewhere,  whicli  is 
almost  necessary  to  recovery,  may  raise  a  doubt  as  to  whether  the  suppu- 
ration may  not  have  been  of  other  than  tubercular  origin.  It  is  suffi- 
ciently obvious  that  destruction  of  a  kidney  by  calculous  pyelitis  or  some 
other  form  of  supi)uration  is  a  less  dangerous  process  than  when  a  dis- 
seminating growtii  is  the  agent;  but  there  is  no  reason  to  doubt  that  tu- 
bercular disease  of  the  kidney,  as  of  the  lung,  may  sometimes  be  restricted 
and  be  outlived,  though  the  frequency  with  which  other  organs  partici- 
pate, as  shown   at  page  85,  is  a  discouraging  fact  in  its  natural  history. 

The  treatment  of  renal  tuberculosis  involves,  first,  that  of  the  consti- 
tutional condition,  and  may  be  much  that  called  for  if  the  consumption 
were  pulmonary  instead  of  renal — nourishing  diet,  sea-air,  iron,  quinine, 
and  the  general  anti-tuberculous  regimen.  The  tendency  of  the  urine 
to  alkalinity,  and,  when  alkaline,  to  putrescence,  with  possible  results  in 
the  way  of  septic  absorption,  may  be  met  by  the  use  of  the  mineral  acids> 


TUBERCLE.  93 

quinine,  and  perchloride  of  iron.  I  have  sometimes  found  distinct  ad- 
vantage, when  the  urine  has  been  offensive,  from  the  use  of  creasote  by 
the  mouth,  though  I  think  that  such  antiseptic  treatment  is  not  so  often 
called  for  as  when  urine  is  locked  up  in  the  pelvis  in  consequence  of 
stone.  The  bladder-symjitoms,  which  are  often  pressing,  and  may  be 
regarded  as  generally  necessary  to  the  disease,  may  be  palliated  by  pa- 
reira,  with  hyoscyamus  or  belladonna  and  opium,  or  by  these  sedatives  as 
suppositories. 

It  is  scarcely  necessary  to  dwell  upon  the  surgical  considerations.  I 
have  known  a  distended  and  tuberculous  kidney  to  be  punctured  with  the 
aspirator  with  relief. 

With  regard  to  the  excision,  it  must  be  presumed  that  so  dangerous 
an  operation  would  not  be  justifiable,  were  not  permanent  cure  likely  to 
ensue  upon  its  immediate  success.  It  has  been  shown  (p.  86)  that  both 
kidneys  are  affected  by  tubercular  disease  about  as  often  as  one  alone; 
and  further,  that,  given  advanced  renal  disease  of  this  nature,  there  is 
only  about  one  case  in  seven  in  which  the  formation  is  not  shared  by 
other  organs.  These  facts  would  appear  enough  to  discourage,  and 
probably  to  prohibit,  the  operation.  It  was  performed  fatally  by  Peters, 
in  a  case  referred  to  in  the  table  in  Chajiter  XIV.  Lucas'  removed  a 
supposed  tuberculous  kidney  with  success,  but  as  the  organ  was  described 
only  as  containing  abscess-cavities,  there  must  remain  doubt  as  to  the 
nature  of  the  disease.  Baker^  removed  with  present  success,  from  a 
child  of  seven,  a  kidney  which  proved  to  be  tuberculous:  six  months 
afterwards  the  urine  still  contained  pus.  Dr.  Goodhart'  and  Mr.  Golding 
Bird  record  the  unsuccessful  excision  of  a  scrofulous  kidney  from  a  man 
of  the  age  of  twenty-seven,  who  had  a  temperature  which  ranged  from 
100  to  104.  The  operation  proved  tedious  and  difficult,  and  the  patient 
died  four  hours  afterwards.  The  tubercular  disease  proved  to  be  con- 
fined to  the  kidney,  which  had  been  removed,  excepting  that  it  involved 
the  ureter  and  to  a  slight  extent  the  bladder.  Dr.  Cole^  of  Bath  has  re- 
corded an  interesting  instance  in  which  a  tubercular  kidney  would  have 
been  extirpated,  had  not  the  patient  begun  to  die  on  the  day  before  that 
fixed  for  the  operation.  It  was  found  that  the  kidney  not  in  question 
had  been  so  completely  destroyed  by  antecedent  disease  of  the  same  na- 
ture, that  the  removal  of  the  organ  to  which  the  symptoms  referred 
would  have  taken  away  all  that  remained  of  the  secreting  tissue. 

'  Trans.  International  Med.  Congress,  vol.  ii.  p.  271. 
2  Trans.  International  Med.  Congress,  1881,  vol.  ii.  p.  262. 
'  Clinical  Transactions,  vol.  xv.  p.  139. 
*Brit.  Med.  Journ.  Aug.  5th,  1882. 


CHAPTER  IX. 
HYDRONEPHROSIS   AND   PYONEPHROSIS. 


Whek  the  cavity  of  the  kidney  is  extended  by  aqueous  fluid,  the  con- 
dition is  described  as  hydronephrosis;  when  by  purulent  fluid,  as  pyone- 
phrosis. Hydronephrosis,  hydrops  renum,  or  dropsy  of  the  kidney,  is  a 
condition  to  which  much  practical  interest  attaches,  since  it  is  apt  to 
present  itself  as  an  abdominal  cyst  of  which  the  nature  may  be  mistaken, 
and  with  regard  to  which  questions  of  operation  may  present  themselves, 
whether  it  be  recognized  as  renal,  or  regarded  as  ovarian,  or  as  ascites. 
Hydronephrosis  may  be  congenital  or  acquired,  of  either  kidney  or  of 
both,  constant,  variable,  or  intermittent. 

It  is  difficult  to  draw  a  line  which  shall  always  hold  good  between 
hydronephrosis  and  dilatation,  for  hydronephrosis  is  only  extreme  dila- 
tation. For  the  most  part  hydronephrosis  affects  one  kidney  only,  and 
arises  in  obstruction  of  the  ureter;  the  accumulation  is  now  cut  off  more 
or  less  completely  from  the  vesical  cavity,  is  not  relieved  by  the  empty- 
ing of  it,  and  consists  not  so  much  of  urine  as  of  an  aqueous  fluid  which 
bears  only  a  remote  resemblance  to  it.  The  distention  is  here  persistent 
as  well  as  extreme,  and  the  distinctions  between  this  condition  and  the 
more  passing  kinds  of  dilatation  are  sufficiently  marked.  They  hold 
good  no  less  when  both  kidneys  are  affected,  as  they  sometimes  are,  from 
similar  or  accidentally  concurrent  stop])ages  of  both  ureters.  But  the 
name  is  also  applied  to  extreme  dilatation  of  the  urinary  cavities  from 
obstructions  in  the  urethra  or  bladder,  in  which  the  distending  fluid  is 
urine  not  at  all  or  but  little  altered;  in  such  circumstances  it  may  be  a 
somewhat  arbitrary  matter  to  decide  whether  hydronephrosis  or  dilatation 
shall  be  the  term  employed. 

The  following  account  of  hydro-  and  pyonephrosis  is  based  in  part 
upon  an  analysis  of  sixty-nine  cases  completed  hy  pof^t-morfcm  examina- 
tion, which  I  have  brought  together  from  various  publications,  the  de- 
scriptions of  preparations  which  I  have  had  opportunitions  of  examining 
in  several  museums,  and  my  own  practice.  1  may  say  that  twenty-two 
of  the  whole  number  are  derived  from  the  records  of  St.  George's  and 
the  Hospital  for  Sick  Children,  and  are  for  the  most  part  unpublished. 
In  collating  i)ublished  cases  I  have  been  greatly  indebted  to  the  paper  ol 
Mr.  Henry  Morris,  in  the  fifty-ninth  volume  of  the  "  Medico- Chirurgi- 
cal  Transactions."  My  records  contain  forty-three  cases  of  single,  six- 
teen of  double,  hydronephrosis,  and  ten  of  i)yonephrosis.  This  may  rep- 
resent the  relative  frequency  of  these  conditions.  It  is  not  practicable  to 
separate  the  consideration  of  pyonephrosis  from  that  of  hydronephrosis 


HYDRONEPHROSIS    AND    PYONEPHROSIS.  95 

flince  the  two  conditions  are  usually  but  different  phases  of  the  same 
disease. 

Hydronephrosis  is  distributed  between  the  sexes,  like  most  renal  dis- 
eases, with  a  slight  preponderance  towards  the  male  side.  Of  sixty-one 
cases  of  hydro-  and  pyonephrosis,  certified  hj  posf-mo7'tem  examination,  of 
which  I  have  records  to  the  point,  thirty-two  belonged  to  the  male  and 
twenty-nine  to  the  female  sex. 

This  is  of  interest  in  relation  to  the  origin  of  the  renal  in  uterine  dis- 
ease, which  would  seem  not  frequent  enough,  in  comparison  with  other 
causes,  to  give  preponderance  to  the  female  sex. 

With  regard  to  age,  none  is  exempt.  Of  51  of  the  above-mentioned 
cases,  in  which  the  age  is  stated,  death  occurred  at  birth,  or  within  a  few 
liours  of  it,  in  3;  during  the  first  year  of  life  in  5;  between  the  ages  of 
1  and  10  in  10;  between  11  and  20  in  5;  between  21  and  30  in  6;  between 
31  and  40  in  8;  between  41  and  50  in  9;  between  51  and  60  in  2;  between 
■U  and  70  in  1;  between  71  and  80  in  2.  Thus  death  from  this  cause 
is  especially  frequent  during  the  first  ten  years  of  life,  as  the  result  of 
congenital  lesions;  as  an  acquired  disease,  largely  due  to  stone,  it  pro- 
duces its  fatal  issue  with  increasing  frequency  up  to  50,  beyond  which 
age  it  is  seldom  delayed. 

Of  the  cases  in  which  hydro-  or  pyonephrosis  affected  one  kidney 
only,  the  side  is  stated  in  45;  25  left,  20  right.  It  is  probable  that  this 
difference  is  accidental;  I  do  not  find  that  stone,  apart  from  hydroneph- 
rosis, exhibits  any  decided  preference  for  one  side. 

For  the  causes  of  hydro-  and  pyonephosis  I  might  refer  to  the 
chapter  on  Diseases  of  the  Ureter  as  comprising  their  greater  number; 
but  as  all  could  not  be  here  included  it  is  needful  to  take  them  into 
separate  consideration.  For  the  production  of  the  great  dilatation  to 
wiiich  these  names  are  given  it  is  generally  needful  that  the  exit  of  the 
ex])anding  cavity  or  cavities  should  be  obstructed,  but  not  completely 
and  finally.  Cases  are  known  to  occur,  like  one  recorded  by  Eayer  (vol. 
iii.  p.  488),  in  which  the  ureter  Avas  from  the  first  impervious  and  incom- 
l)lete,  but  as  a  rule  such  absolute  and  permanent  stoppages  are  attended 
with  atrophy  of  the  kidney,  its  extensive  dilatation  commonly  being  due 
to  an  obstruction  which  is  either  incomplete  or  intermitting. 

It  is  certain  that  a  larger  number  of  cases  of  hydro-  and  pyonephro- 
sis are  due  to  stone  than  to  any  other  cause;  as  compared  with  this  all 
other  causes  are,  separately,  of  slight  frequency,  though  they  appear 
numerous  when  taken  together.  Many  of  the  causes  which  have  been 
assigned  to  the  disease — obliquities,  twists,  and  valvular  openings  of  the 
ureter,  may,  with  as  much  jirobability,  be  placed  among  its  cou- 
■iquences. 

In  the  collection  of  cases  to  which  I  nave  referred,  comprising  sixty- 
nine /jo.s^-wior^e?^  examinations  of  hydro-  and  pyonephrosis,  the  causes  of 
Mie  dilatation,  or  in  other  words  the  nature  of  the  obstruction,  is  thus 
Lated: — 


•96 


HYDRONEPHROSIS    AND    PYONEPHROSIS. 


Causes  of  Single  Hydro-  and  Pyonephrosis. 

Hydro- 
neph- 
rosis 
43  cases 

Pyo- 
neph- 
rosis 
10  cases 

Total 

of 

both 

53  cases 

Calculus  in  aflfected  kidney  ov  ureter 

11 

2 
1 

G 

17 

Calculus  in  unaffected    kidney,    cause  of    obstixiction    not 

further  ascertained,  presumably  a  stricture  left  by  a  stone. 

Villous  growth  from  pelvis  of  kidney 

2 
1 

Congenital  impei'viousness  of  ureter 

1      1      .. 

1     1      .  - 

1 

Compression  of  ureter  by  swollen  lymphatic  gland 

1 

"                    •'            cancer  of  pancreas 

"                    "            band  of  peritoneal  adhesion 

"                     "            abnormal  branch  of  renal  artery. . . 
Stricture  of  ureter  the  result  of  a  kick 

1 
1 

1 

i 
1 

5 

1 
6 
1 
9 

•• 

'i 
1 

*2 

1 

1 
1 
1 

Ureter  degenerated  into  solid  cord 

1 

"      of  small  calibre 

1 

Sudden  bend  in  ureter 

1 

Valvular  structure  or  arrangement,  or  obliquity  of  position, 

in  connection  with  renal  origin  of  ureter 

Valvular  structure  in  connection  with  vesical  exit  of  ureter.. 
Stricture  of  ureter  of  unexplained  nature 

5 

1 
6 

Villous  tumor  of  bladder  affecting  orifices  of  ureters 

Cause  not  satisfactorily  ascertained 

1 
11 

43 

10 

53 

Causes  of  Double  Hydronex)hrosis — 16  cases. 

Calculi  in  both  kidneys ,  .  .  .  . 

Calculus  in  one  kidney  or  ureter,  stricture  in  other  ureter,  possibly 

of  calculous  origin,  .... 

Corkscrew  twist  in  both  ureter, 
Abnormal  arrangement  of  renal  artery  compressing  one  ureter 

congenital  narrowing  of  the  other, 
Stone  in  bladder,  ..... 

Stricture  at  neck  of  bladder,      .... 
Congenital  stricture  or  imperfection  of  urethra. 
Stricture  of  urethra,  not  congenital,     . 
Congenital  obstruction  aj^pai-ently  in  urethra,   but  not   clearly 

ascertained,  ...... 

Diabetes  insipidus,  ..... 

Cause  not  ascertained,    ..... 


2 
1 

1 
2 
1 
2 
1 

3 
1 
1 

16 


It  is  at  once  seen  that  the  causes  of  the  single  and  of  the  double  affec- 
tions are  for  the  most  part  different.  The  dilatation  when  one-sided  is 
invariably  due  to  obstruction  of  the  ureter  or  its  orifices;  when  bilateral 
it  is  in  some  cases  due  to  simultaneous  obstruction  of  both  ureters,  but 
more  often  to  hindrance  in  the  exits  common  to  both  kidneys,  the  blad- 
der and  urethra. 

Taking  one-sided  dilatation  first,  it  is  seen  that  of  42  cases  in  which 
the  nature  of  the  obstruction  was  ascertained  this  was  clearly  due  in  17 
cases  to  stone  in  the  kidney  or  ureter,  while  in  2  others  calculus  in  the 
unaffected  kidney  suggested  the  probability  that  there  had  once  been  a 
stoppage  of  the  same  nature  on  the  side  which  was  the  scat  of  the  ob- 
struction. A  small  stone  may  lodge  for  a  time  in  the  ureter,  and  then 
pass  out,  leaving  an  abrasion,  which  will  eventuate  in  a  cicatrix  and  a 
stricture.     It  is  possible  that  some  of  the  cases  in  which  only  an  unex- 


HYDRONEPHROSIS    AND    PYONEPHROSIS.  97 

plained  stricture  of  the  ureter  has  been  found  may  have  had  such  an 
origin.  Causes  of  compression  of  tiie  ureter  external  to  itself,  tumors, 
enlarged  glands,  and  bands  of  adhesion  find  place,  but  it  is  to  be  noted 
that  disease  of  the  uterine  organs  is  not  frequent  in  this  relation. 

Cancer  of  the  uterus  is  apt  to  involve  both  ureters  rather  than  one 
only,  and  then  appears  seldom  to  cause  the  larger  degrees  of  dilatation 
which  are  now  under  discussion.  Suppression  of  urine  would  seem  to  be 
a  more  common  result  of  such  lesions  than  hydronephrosis.  The  tra- 
versing of  tlie  upper  part  of  the  ureter  by  an  abnormal  branch  of  the 
■onal  artery  is  generally  accepted  as  a  cause,  however  infrequent,  of  its 
obstruction.  It  might  have  been  supposed  that  the  relaxation  of  the 
artery  during  diastole  would  have  afforded  sufficient  exit. 

Another  class  of  causes  is  still  more  problematical.  A  comparatively 
large  number  of  cases  are  attributed  to  obliquities,  sudden  bends,  and 
valvular  arrangements  of  the  ureter  at  its  origin.  It  is  obvious  that  if 
the  pelvis  be  dilated  more  on  one  side  of  the  origin  of  the  ureter  than  the 
other  (and  such  irregularity  often  happens)  the  origin  of  that  tube  may 
be  subjected  to  lateral  compression  or  made  to  slant,  so  that  the  meni- 
brane  on  one  side  may  overhang  and  perhaps  occlude  the  orifice;  but  it 
may  be  suggested  that  in  many  or  most  of  these  cases  the  distortion  of 
the  orifice  is  in  the  first  place  the  result  of  dilatation  of  the  pelvis,  though 
it  may  be  a  means  of  increasing  it.  Great  extension  of  the  pelvis 
must  necessarily  change  the  position  and  relations  of  its  duct. 

In  the  case,  for  example,  of  congenital  hydronephrosis  'reported  l)y 
:\Ir.  Glass  ("  Phil.  Trans.,"  1746),  where  the  cyst  held  thirty  gallons,  the 
ureter,  which  was  not  otherwise  obstructed,  was  abruptly  bent  and  opened 
obliquely  into  it.  It  is  clear  that  much  displacement  of  the  ureter  was 
inevitable  as  a  result  of  the  distention;  we  are  left  in  doubt  as  to  its 
original  cause,  save  that  it  was  not  a  permanent  and  complete  organic 
stricture.  One  case  is  referred  to  from  St.  George's  Hospital,  in  which 
the  obstruction,  which  was  of  intra-uterine  origin,  was  a  loose  fold  of 
mucous  membrane  in  the  ureter  within  the  vesical  wall;  this  presents 
itself  as  a  first  cause  with  more  probability  than  the  valvular  arrange- 
ments which  are  so  often  found  at  the  junction  of  the  ureter  and  the  dis- 
tended pelvis. 

Much  dilatation  has  been  known,  as  in  a  case  reported  by  Mr.  Morris,* 
to  follow  upon  vesical  growths  involving  the  orifices  of  one  or  both 
ureters.  In  Mr.  Morris's  case  there  were  growths  in  connection  with  both 
orifices;  one  kidney  was  dilated,  the  other  atrophied.  Lastly,  injuries  of 
the  ureter  by  violence  from  without — in  one  case  by  a  kick  from  a  horse,' 
in  another  by  a  fall  at  leap-frog — were  followed  by  obstruction  and  ac- 
cumulation, whether  of  aqueous  or  purulent  matter. 

Double  hydronephrosis  depended  upon  obstructions  in  or  about  the 
bladder  or  urethra  in  a  proportion  of  nine  instances  out  of  fifteen,  in 
which  the  seat  of  the  difficulty  was  approximately  ascertained.  In  the 
majority  of  these  cases  the  obstruction  was  congenital  and  involved  the 
urethra.  An  instance  has  been  recorded  in  which  the  obstruction  was 
apparently  a  membranous  obstruction  at  the  vesical  end  of  the  urethra. 
This  was  broken  down  with  a  sound,  after  which  urine  was  passed  freely, 
and  the  swelling  disappeared.  The  child,  three  days  old  at  the  time  of 
the  operation,  had  passed  no  urine  since  birth. ^ 

>  Med.  Chir.  Trans,  vol.  lix.  p.  233. 

*  See  chapter  on  Diseases  of  tlie  Ureter. 

*  Lamotte,  quoted  by  Morris,  Aled.  Chir.  Trans,  vol.  ix. 

7 


98  HYDRONEPHROSIS    AND   PYONEPHROSIS. 

A  peculiar  obstruction  has  been  described  by  Dr.  Hare  as  tlie  cause  of 
double  hydroncplirosis,  which,  like  many  of  the  hiterai  and  valvuUir  ori- 
fices so  common  witli  tlie  uuilateral  condition,  may  not  improbably  be  its 
result.  Each  ureter  was  coiled,  at  a  little  distance  from  its  origin,  "  like 
a  turn  and  a  half  of  a  corkscrew  brought  closely  together,"  the  coils  being 
adherent  to  the  dilated  pelvis,  and  held  together  by  the  tissues  around, 
upon  the  detachment  of  which  by  dissection  the  channel  gave  ready  exit 
to  the  accumulation  above,  which  before  could  not  pass,  even  when  the 
kidney  was  subjected  to  i)ressure.  It  is  to  be  suggested  that  the  coiled 
condition  may  have  resulted  from  some  process  in  the  course  of  disease, 
whereby  the  extremities  of  each  ureter  have  been  unnaturally  a[)proxi- 
mated;  each  duct  would  thus  have  a  su[)erfluity  of  length  which  must  be 
disposed  of  in  curves  of  coils,  or  otherwise  than  as  a  straight  line.  Hypo- 
thetically,  the  ureters  might  be  rendered  longer  than  their  course  by  de- 
l^ression  of  their  orifices,  such  as  might  arise  from  enlargement  of  the 
l)elves,  by  elevation  of  their  exits  from  distention  or  displacement  of  the 
bladder,  or  by  elongation  of  the  ureters  themselves  as  the  consequence  of 
dilatation.  The  conditions,  whatever  they  were,  which  preceded  the 
twists  were  in  the  end  obscured  by  their  results;  these  circumvolutions, 
like  the  bends  and  valvular  entrances  so  often  described,  though  probably 
not  the  originators  of  the  distention,  were  at  least  causes  of  its  increase. 
One  case  of  double  hydronephrosis  is  ascribed  to  pressure  upon  one  ureter 
by  an  abnoryial  branch  of  the  renal  artery,  while  the  duct  on  the  other 
side  was  congenitally  narrowed.  Diabetes  insipidus,  by  means  probably 
of  the  profuse  secretion  of  urine  which  it  entails,  causes  extreme  dilata- 
tion of  both  kidneys,  which  may  be  called  hydronephrosis,  if  dilatation 
due  to  Urethral  or  vesical  obstruction  be  so  termed. 

When  hydronephrosis  arises  before  birth,  the  swelling  may  be  enough 
to  cause  difficult  labor.  The  child  may  be  stillborn  or  perish  in  early 
infancy,  or  the  cause  may,  particularly  if  one  kidney  only  be  affected, 
operate  gradually  and  declare  itself  only  in  advanced  life. 

Disease  of  the  uterus  or  ovaries  is  a  frequent  cause  of  the  lesser  de- 
grees of  hydronephrosis,  which  are  usually  described  as  dilatation.  Dr. 
Koberts,  in  collating  the  causes  of  fifty-two  cases  of  hydrone|)hrosis,  as- 
signs six  to  encroachment  upon  the  ureters  of  the  disease  of  the  uterus, 
ovaries,  or  pelvic  organs.  Cancer  of  the  uterus,  starting  equidistant  from 
both  ureters,  is  apt  to  involve  both,  if  either,  and  seldom  gives  rise  to 
enough  swelling  to  cause  a  tumor  palpable  during  life.  Mr.  Morris  ob- 
serves that  at  the  Middlesex  Hospital,  where  the  cancer  wards  sui)ply  a 
large  number  of  cases  of  cancer  of  the  pelvic  organs,  and  where  scarcely 
a  week  passes  without  the  presentation  in  the  dead-house  of  some  degree 
of  hydronephrosis  from  this  cause,  yet  that  none  of  the  present  surgeons 
remember  to  have  detected  an  abdominal  swelling  of  this  nature  during 
life.  The  comparative  rapidity  of  malignant  disease,  and  the  fact  that 
both  sides  are  so  often  involved,  does  not  give  the  opportunity  for  ex- 
treme expansion  which  is  found  with  more  chronic  conditions,  and  where 
one  kidney  is  left  to  perform  the  function  of  both.  Displacements,  also, 
of  the  uterus  may  cause  obstruction  of  the  ureters  and  accumulation  in 
the  kidneys,  though  perhaps  not  enough  to  give  rise  to  tumors  tangible 
clinically.  Retroflexion  of  the  uterus  has  been  shown  to  bend  and  so  ob- 
struct the  ureters  as  they  pass  by  its  side,  and  prolapse  to  displace  the 
bladder  and  compress  the  ureteral  exits. 

The  obstruction  which  gives  rise  to  hydronephrosis  is,  as  already 
stated,  usually  incomplete.     Instances  are  known  in  which  the  pelvis  of 


HYDRONEPHROSIS    AND    PYONEPHROSIS. 


99 


the  kidney  has  heen  without  exit  from  the  first,  and  the  child  born  with 
hydronephrotic  distention,  as  in  a  case  quoted  by  Rayer,  from  Billard ; 
but  more  often  in  such  circumstances  the  kidney  is  simply  atrophied. 
Occasionally  in  older  subjects  great  dilatation  has  been  found  to  be  due 
to  a  stone,  which  after  death  at  least  appears  completely  to  block  the  in- 
fundibulum;  but  such  obstacles  have  necessarily  been  of  slow  formation 
and  the  stopj^age  long  imperfect.     As  regards  the  course  of  the  ureter,  a 


.  -^^^^.^I'^n  of  a  kidney  dilated  in  consequence  of  the  impaction  of  calculi.  The  expansion  of  the 
intunilibulnm  and  calyces,  the  latter  of  which  open  like  diverticula  into  the  pelvis,  is  well  shown . 
ine  calculi,  which  were  of  uric  acid,  have  not  been  preserved.  .  (From a  preparation  at  the  Loudon 
rlospitai.) 

perhaps  narrow,  but  not  impervious,  stricture  in  connection  witli  stone 
is  a  more  common  cause  of  hydronephrosis  than  the  impassable  lodgment 
of  stone  itself.  The  rule  is,  that  if  the  adult  kidney  become  suddenly 
and  completely  occluded,  the  consequent  dilatation  is  not  excessive. 
Wlien  the  ureter  is  stopped  two  processes  ensue — dilatation  and  atrophy, 
when  the  stoppage  is  incomplete  the  former  predominates,  when  complete 


100 


HYDRONEPHROSIS    AND    PYONEPHROSIS. 


the  latter.  The  urine  is  secreted  with  so  little  force  that  the  point  of 
accumulation  is  soon  reached  which  i^uts  an  end  to  it.  The  ghmd  will 
now  secrete  only  as  much  as  is  removed  by  absorption  and  leakage.  The 
absorption  is  insignificant;  if  there  be  no  leakage  the   secretion  will  be 


A  kidney  which  lias  become  converted  into  a  dehcate  transhicent  cyst,  nothing  apparently  re- 
maining but  the  cai)sule,  tlie  pelvic  lining,  and  some  septa,  which  indicate  the  original  structure  of 
the  organ.  The  ureter  liangs  down  similarly  stretched  and  attenuated.  The  kidney  is  but  little 
enlarged  externally,  however  extended  within.  There  is  no  record  of  the  nature  of  the  obstruc- 
tion—it may  have  been  stone.    (From  a  preparation  at  the  Middlesex  Hospital.) 

virtually  at  an  end,  and  the  organ  become  effete  from  disuse  ;  if  there 
be  leakage  the  secretion  will  go  on  pari  passu,  the  activity  of  the  gland 


HYDRONEPHROSIS    AND    PYONEPHROSIS.  101 

be  maintained,  and  with  it  a  slight  but  constant  pressure  upon  the 
cavity.  Reviewing  the  causes  of  hydronephrosis — meaning  by  this  dila- 
tation enough  to  be  palable  during  life — it  is  clear  that  the  majority  in- 
volve only  partial  or  intermitting  stoppyge:  stricture  rather  tlian  oblitera- 
tion, injuries  caused  by  stones  more  often  than  their  impassable  fixture, 
valvular  entrances  and  exits,  obliquities,  twists,  and  external  pressure, 
whether  by  arteries  or  growths. 

Given  the  required  obstruction — necessarily  incomplete,  should  both 
sides  be  involved,  as  deatli  by  suppression  would  prevent  any  chronic 
changes — and  a  sufficiency  of  secreting  tissue,  distention,  and  dilatation 
of  the  pelvis  may  ensue  which,  according  to  its  contents,  is  hydro-  or 
pyonephrosis.  Pyonephrosis  is  hydronephrosis  ^j/?^?  pyelitis.  The  mam- 
millary  processes  are  replaced  by  depressions,  and  the  cones  by  excavations, 
which  increase  until  they  are  separated  from  each  other  only  by  plates 
of  condensed  fibrous  tissue,  while  the  contact  of  the  [)elvic  membrane 
with  the  capsule  is  prevented  possibly  only  by  remnants  of  renal  tissue,, 
scarcely  recognizable  except  with  the  microscope.  As  the  swelling  in- 
creases it  loses  more  and  more  of  its  renal  character,  retaining,  however,, 
in  most  cases  something  of  the  renal  outline,  and  still  having  abbreviated 
partitions,  or  radial  folds  on  its  inner  surface. 

The  organ  in  extreme  cases  will  expand  into  a  thin  ovoid  cyst,  wliichy 
as  far  as  regards  the  outside,  is  to  be  recognized  as  renal  only  by  its  re- 
lations to  the  ureter  and.  the  colon,  which  latter  is  usually  inseparable- 
from  its  surface.  If  the  inside  of  such  a  cyst  be  examined,  it  is  possible 
that  all  septa,  may  have  disappeared,  but  a  record  of  the  renal  structure 
be  still  preserved  in  a  peculiar  delineation,  for  it  may  be  little  more, 
which  marks  the  places  where  the  mamillary  processes  pierced  the  pelvic 
membrane.  The  lining  of  the  cyst  may  present  an  arrangement  of 
round  holes,  which  look  as  if  they  had  been  punched,  through  whicli 
protrude  thin  laminae,  which  are  the  attenuated  and  extended  cones. 
The  effect  is  that  of  a  "slashed  doublet,"  the  lining  showing  through  the 
cuts.  The  dimensions  of  such  a  cyst  may  be  great,  or  even  gigantic. 
In  a  boy  of  eight  at  the  Hospital  for  Sick  Children,  the  longer  and  shorter 
diameter  of  an  ovoid  cyst  of  this  nature  were  nine  and  eight  inches,  and 
its  contents  eighty-three  ounces.  This,  though  large  for  so  small  a  sub- 
ject, is  enormously  exceeded  in  the  adult.  I  have  elsewhere  (p.  55)  referred 
to  a  largely  dilateil  kidney,  which  had  given  lodgment  to  an  accumulation 
of  colloid  materia,l:  the  kidney,  which  still  retained  its  shape,  measured 
eleven  inches  by  six,  and  far  larger  examples  could  be  cited,  the  only 
limit  being  the  ca[)acity  of  the  trunk.  The  largest  instance  on  record  is 
probably  one  which  I  havft  already  referred  to,  and  whicli  has  been  quoted 
by  Dr.  Roberts,  from  the  report  of  Mr.  Glass  in  the  "  PIiiloso])hical 
Transactions"  for  1747.  A  woman,  who  had  been  dropsical  from  birth, 
died  at  the  age  of  twenty-two;  her  belly  then  had  the  circumference  of 
six  feet  four  inches,  and  measured  four  feet  and  half  an  inch  from  the 
ensiform  cartilage  to  the  pubes.  The  swelling  was  produced  by  a  cyst, 
which  represented  the  right  kiddey,  and  held  thirty  gallons  all  but  a  pint 
of  liquid,  limpid  as  urine,  but  lightly  tinged  of  a  coffee  color.  The  ure- 
ter opened  into  this  cyst  without  recognized  obstruction. 

The  distention  of  hydronephrosis  is  usually  general  to  the  pelvis,  but 
instances  occur  in  which  it  is  limited  to  a  portion  of  its  wall,  and  others 
in  which  a  cyst  from  the  outside  has  become  connected  with  the  renal 
cavity.  As  an  instance  of  partial  or  local  dilatation,  there  is  a  prepara- 
tion at  St.  George's  Hospital  which  exhibits  a  great  expansion,  limited  to 


102  HYDRONEPHROSIS    AND    PYONEPHROSIS. 

the  top  of  the  ureter  and  its  funnel-shaped  entrance,  the  pelvis  itself  being 
elsewhere  but  little  affected.  This  superadded  cavity,  which  may  have 
held  half  a  pint,  stretches  inward  from  the  kidney,  and  must  have  ex- 
tended during  life  across  the  vertebral  column. 

The  contents  of  the  cavities  whicli  have  been  described  are  watery  or 
purulent,  as  their  names  imply.  AVithin  the  term  hydronephrosis  there 
is  a  considerable  variety.  If  the  dilatation,  as  often  in  double  hydro- 
nephrosis, be  common  to  all  the  urinary  cavities,  their  contents  will  be 
urine,  little  changed,  save  that  the  specific  gravity  may  be  low,  as  with 
urine  secreted  against  pressure,  and  it  may  have  become  ammoniacal. 
Ill  Dr.  Little's  case,  where  botli  kidneys  were  distended  from  a  congeni- 
tal obstruction  below  the  bladder,  tlie  fluid  withdrawn  by  tapping  had  a 
urinous  smell,  and  contained  urea  and  uric  acid,  but  had  a  specific  grav- 
ity of  only  1.004.  It  is  sufficiently  obvious  that,  when  hydronephrosis 
depends  upon  stoppage  below  the  bladder,  as  in  most  cases  of  congenital 
origin,  the  collected  fluid  is  necessarily  urinous,  since  it  contains  the 
"whole  renal  secretion.  When  the  dilatation  is  of  one  kidney  only,  the 
destruction  or  metamorphosis  of  the  organ  may  be  carried  further  than 
is  consistent  witli  life  where  both  are  involved;  but  even  in  the  most  ex- 
treme of  these  cases,  if  the  cyst  be  actually  a  dilatation  of  the  kidney,  the 
fluid  gives  evidence  of  urinary  constituents,  unless  much  clianged  by  de- 
composition, or  replaced  by  suppuration  or  colloid.  Tiie  fluid  found  in 
unilateral  dilatation  is  usually  clear,  either  aqueous  or  albuminous,  uri- 
nous in  appearance  and  smell,  and  giving  evidence  of  urea  and  uric  acid 
to  chemical  tests.  It  has  sometimes  been  dark  in  color,  probably  from 
blood;  the  liquid  in  Mr.  Glass's  case  was  limpid  as  urine,  but  of  a 
coffee  color.  In  otiier  cases,  it  has  been  ammoniacal  and  offensive.  In 
Dr.  Hillicr's  case,  the  fluid  withdrawn  from  the  cyst  during  life  was  foe- 
tid, highly  albuminous,  and  contained  urea;  that  removed  after  death  was 
clear,  pale,  urinous  in  smell;  it  contained  a  mere  trace  of  albumin,  and 
had  a  specific  gravity  of  1.002.'  Mr.  Cooper  Rose  has  described  a  case  of 
liydronepiirosis  which  was  tapped,  witii  tlie  result  of  a  permanent  fistula 
and  tlie  habitual  issue^  of  a  foetid  discharge,  in  which  none  of  the  ele- 
ments of  urine  could  be  detected.  In  ]\Ir.  Caesar  Hawkins's  case,  else- 
wiiere  referred  to  (p.  119),  where  tlie  cyst  was  virtually  external  to  the 
kidney,  however  closely  connected  with  it,  the  absence  of  special  urinary 
constituents  Avas  ascertained  by  Dr.  Prout;  and  it  may,  perliaps,  gener- 
ally be  inferred  that,  if  aqueous  or  simply  serous  fluid,  not  obviously  pu- 
trid, be  found  to  be  free  from  urea,  it  is  not  from  a  hydronephrosis.  If 
the  cavity  be  altered  by  suppuration,  the  contents  may  be  either  such  as 
Hiave  been  described,  more  or  less  mingled  with  pus,  or  may  be  sim[)ly 
purulent,  the  pus  possibly  not  differing  appreciably  from  pus  formed  in 
other  situation.  A  truly  hydronephrotic  cavity  may  become  filled  with 
a  gelatinous  material,  having  all  the  cliaracters  of  colloid  cancer,  as  in 
the  case  already  referred  to,  and  in  another  of  the  same  kind  which  has 
since  been  ])ublislied  by  Damreicher.  Cholesterin  has  been  found  in  tiie 
fluid  of  hydronephrosis.^ 

The  symptoms  of  hydronephrosis,  when  it  is  congenital  and  double, 
are — to  place  them  in  the  order  in  which  they  present  themselves — possi- 
bly difficult  labor,  abdominal  tumor,  absence  of  urine,  and  death,  unless 

'  Med.-Chir.  Trans,  vols,  xviii.  and  lii. 

■'  Ibid.  vol.  li. 

«  Dr.  Coghill,  Edm.  Med.  Journ.  Feb.,  1875,  p.  747. 


HYDRONEPHROSIS    AND    PYONEPHROSIS.  103 

the  urethra  can  be  made  pervious  within  perhaps  two  days  of  birth.  If 
the  obstruction  be  incomplete,  in  which  case  it  may  long  escape  notice, 
the  disease  may  not  cause  death  until  much  later.  Instances  have  been 
published  by  Broadbent,  Faber,  and  Little,  in  which  distention  of  both 
kidneys  with  their  ducts,  of  congenital  origin,  proved  fatal  at  the  ages 
respectively  of  three  months,  5|  and  6^  years.  The  case  fatal  at  the  age 
of  5|  was  so  suddenly,  after  a  fall;  with  that  of  6|,  death  was  preceded 
by  convulsions  and  coma.  The  chief  symptom  in  all  was  abdominal 
swelling;  one  which  was  subsequently  tapped  was  at  first  thought  to  be 
ascites. 

When  hydronephrosis  presents  itself  later,  its  course  is  ruled  by  that  of 
the  disease  upon  which  it  is  dependent;  if  unremoved  or  irremovable 
stone  in  the  bladder,  it  is  early  fatal;  if  on  diabetes  insipidus,  it  but  lit- 
tle interferes  with  life.  When  double  hydronephrosis  ensues  as  a  result 
of  calculi  in  both  kidneys,  as  in  a  case  reported  by  Rayer,  or  of  obstruc- 
tion in  both  ureters,  as  is  not  uncommon,  death  may  occur  by  uraemia, 
with  or  without  total  suppression  of  urine.  In  a  case  published  by  Dr. 
Roberts,  in  which  one  ureter  was  compressed  by  a  branch  of  the  renal 
artery,  the  other  narrowed  by  an  old  stricture,  death  was  ])receded  by 
sixty  hours  of  suppression.  It  is  not  necessary  to  describe  the  swellings 
of  double  hydronephrosis,  save  as  cysts  in  the  renal  positions  and  with 
renal  characters  which  have  been  sufficiently  dwelt  upon  in  the  general 
consideration  of  renal  tumors.  Double  tumors  seldom  attain  the  dimen- 
sions of  single  dilatation;  they  are  often  of  unequal  size;  one  often  evi- 
dent during  life,  the  other  not  so.  In  one  of  Rayer's  cases  the  right  kid- 
ney formed  a  sac  eigl)t  inches  by  five,  the  lefc  a  small  membranous  sao 
not  discoverable  until  after  death.  In  others,  particularly  where  the  ob- 
struction has  been  m  the  urethra,  both  have  been  voluminous.  Tlie  more 
or  less  persistent  swellings  of  double,  as  of  single  liydronephrosis  (ex- 
cluding, that  is  to  say,  distentions  like  those  of  diabetes  insipidus,  which 
are  habitually  relieved  with  micturition),  so  frequently  intermit,  either 
spontaneously  or  under  pressure  or  friction,  as  to  be  importantly  charac- 
terized by  their  thus  becoming  relieved  by  urinary  discliarge.  Out  of 
the  sixty-nine  cases  of  hydro-  and  pyonephrosis,  upon  which  this  account 
is  chiefly  based,  subsidence  of  the  tumor  occurred  spontaneously  in  twelve 
cases,  under  friction  in  two.  In  one  of  the  instances  the  discharge  was 
by  the  rectum,  in  the  rest  ascertainably  or  presumably  by  the  urinary  chan- 
nels. This  occurrence  is  more  frequent  with  hydro-  than  with  ])yoneph- 
rosis;  in  the  cases  of  the  latter,  it  took  place  but  once.  It  is  relatively 
more  frequent  with  double  than  with  single  hydronephrosis;  among  the 
sixteen  cases  of  double  hydronephrosis  this  phenomenon  presented  itself 
either  once  or  repeatedly  in  six  patients;  among  the  forty-three  of  single 
hydronephrosis,  it  occurred  in  seven.  This  habit  of  renal  accumulation, 
to  which  especial  attention  has  been  drawn  by  Mr.  Morris  in  the  paper 
already  referred  to,  is  obviously  to  be  associated  with  the  incompleteness 
of  the  stoppage  which  usually  give  rise  to  the  disorder. 

To  revert  to  double  hydronephrosis,  the  general  symptoms,  apart 
from  the  swellings,  are  various;  and,  excepting  the  forms  of  uraemia  and 
constipation  from  pressure  on  the  descending  colon,  may  be  called  acci- 
dental. Febrile  disturbances,  or  signs  of  prostration  described  as  febrile, 
have  been  noted  in  some  cases;  in  others  the  more  definite  results  of 
•urEemia,  vomiting,  convulsion,  and  coma.  Pain  in  the  back  and  other 
immediate  signs  of  urinary  disturbance  sometimes  present  themselves, 
and  also  thirst  and  frequency  of  micturition,  as  the  results  of  the  state 


10-i  HYDRONEPHROSIS    AND    PYONEPHROSIS. 

of  renal  secretion  whicli  belongs  to  the  dilated  condition  of  the  glands. 
The  urine  wlien  it  finds  exit  is  usually  pale,  copious,  of  low  specific 
gravity,  and  often  with  a  trace  of  albumin.  It  has  been  found  to  contain 
blood  and  epithelium  of  pelvic  characters.  It  is  liable  to  occasional  sup- 
pression and  sudden,  often  large,  increase  from  the  overcoming  of  a 
ureteral  obstruction. 

It  is  not  necessary  to  refer  to  the  urine  of  single  hydronephrosis, 
which,  except  at  the  times  of  intermittent  discharge  should  these  occur, 
is  solely  supplied  by  the  undilated  kidney,  and  is  healthy  if  this  be  so. 
It  may  be  albuminous,  bloody,  or  purulent,  as  the  result  of  disease  in  the 
practically  solitary  organ. 

When  hydronephrosis  is  limited  to  one  kidney,  the  cystic  transforma- 
tion of  the  organ  and  consequent  abdominal  swelling  may  be  greater,  as 
already  stated,  than  is  consistent  with  life  where  both  are  involved.  The 
greatest  on  record  is  Mr,  Glass's,  already  referred  to,  where  the  abdomen 
measured  six  feet  four  inches  in  circumference,  the  cyst  held  thirty 
gallons,  the  heart  was  pushed  up  to  the  clavicle,  and  the  lungs  reduced 
by  compression  to  the  size  of  those  of  a  new-born  child.  The  patient  was 
described  as  a  tall,  well-proportioned  woman.  Slie  died  at  the  age  of 
twenty-two.  Smaller,  but  still  considerable,  degrees  of  abdominal  swell- 
ing from  single  hydronephrosis  are  matters  of  familiar  experience  ;  and 
in  many  cases  have  involved  botli  sides  of  the  abdomen.  I  estimate  that, 
in  about  one-fourth  of  the  cases  of  single  hydronephrosis,  the  swelling, 
as  observed  during  life,  has  ceased  to  be  limited  to  the  lateral  half  of  the 
body,  while,  in  perhaps  a  tliird  of  these,  it  has  come  to  occupy  the  greater 
part  of  the  belly.  Wiien  the  cyst  has  transgressed  the  limits  character- 
istic of  renal  tumors,  tiie  dilatation  has  become  great,  tlie  walls  attenu- 
ated, and  the  fluidity  of  the  contents  obvious.  In  tiiese  circumstances  it 
has  been  mistaken  for  ascites,  and  often  for  ovarian  dropsy.  In  Dr. 
Hillier's '  case  at  the  Hospital  for  Sick  Children,  tlie  swelling  was  at 
first  thought  to  be  of  this  nature,  so  large,  so  symmetrical  was  it,  and  so 
superficially  did  it  fluctuate  ;  its  nature  was  first  suggested  by  the  char- 
acter of  the  fluid  withdrawn,  which,  though  albuminous,  was  urinous  in 
smell,  and  contained  urea  und  uric  acid.  The  ovarian  error  is  more  fre- 
quent and  more  important.  I  have  before  me  records  of  seventeen  cases  of 
single  hydronephrosis  in  females:  in  eight  of  these  the  tumor  was  thought 
to  be  ovarian,  in  five  ovariotomy  was  jn-oposed,  and  in  four  attempted.^ 
To  refer  to  pyonephrosis  in  this  connection,  though  somewliat  out  of 
order,  this  error  of  diagnosis  is  somewhat  less  frequent:  with  five  female 
subjects  it  occurred  but  twice.^  Wlien  once  such  a  mistake  is  recognized 
as  one  to  be  guarded  against,  it  should  cease  to  be  possible.  The  de- 
pression of  the  uterus  witli  the  renal  cyst,  as  compared  with  its  elevation 
with  the  ovarian,  should  suggest  farther  inquiry,  part  of  wiiich  should 
be  by  puncture  and  examination  of  the  fluid  for  urinary  constituents.  A 
renal  indication  second  to  none  in  reliability,  but  not  always  present,  is 
the  abrupt  variation  of  the  tumor  in  size  witii  or  without  noticeable  dis- 
charge with  the  urine.  But  I  need  not  recapitulate  the  distinctions 
elsewhere  stated  between  renal  and  ovarian  tumors.  Another  error  of 
diagnosis  has  occurred  in  the  mistaking  of  a  right  hydroueplirosis  for 

'  Med.-Chir.  Trans,  vols,  xlviii.  and  lii. 

"  I  need  make  no  individual  reference  to  these,  as  most  of  them  are  referred  to 
in  Mr.  Morris's  jiaper,  my  obligations  to  which  I  have  already  acknowledged.  Sea 
Med.-Chir.  Trans,  vol.  lix. 

3  Cooper  Rose,  Med.-Chir.  Trans,  vol.  li.  p.  167. 


HYDRONEPHROSIS    AND    PYONEPHROSIS.  105 

hydatid  of  the  liver,  and  the  tumor  in  this  belief  '  been  repeatedly  tapped 
and  injected  with  idione.  The  distinctions  between  hepatic  and  renal 
tumors  have  likewise  found  mention  elsewhere. 

One  of  tlie  most  important  cliaracters  of  renal  dilatation,  whether 
hydro-  or  i)yonephrotic,  is  intermission  by  discharge  into  the  urine, 
whether  spontaneously  or  nnder  pressure  or  friction.  It  has  been  already 
shown  that  these  expansions  usually  result  from  incomplete  closure  ;  the 
consequence  is,  that  when  a  certain  degree  of  fulness  and  of  tension  is 
attained,  or  a  valvular  obstruction  is  so  stretched  as  no  longer  to  act, 
there  is  an  escape,  partial  or  complete,  of  the  accumulation.  The  addi- 
tion to  the  urine  in  these  circumstances  may  attract  notice,  as  im[)arting 
to  it  some  unusual  character;  but  more  often  a  simple  increase  is  ob- 
served, or  the  urinary  change  wholly  eludes  observation.  The  inter- 
mitting habit  of  these  tumors  has  already  been  noticed  in  connection 
with  double  hydronephrosis.  The  accumulation  of  hydronephrosis  when 
on  the  left  side  has  been  known,  like  accumulations  of  pus,  to  enter  the 
descending  colon,  and  tlius  escape  by  the  rectum.* 

Slightly  to  sketch  the  remaining  symptoms  of  single  hydronephrosis, 
it  is  first  to  be  noted  that,  so  long  as  the  other  kidney  be  healthy,  there 
may  be  none  apart  from  tlie  tumefaction,  and  this  may  not  be  such  as  to 
attract  notice.  There  is  at  St.  Gl-eorge's  Hospital  a  kidney  dilated,  as 
the  result  of  stone,  into  a  cyst,  which  must  have  held  nearly  a  gallon, 
and  reached  from  the  pelvis  to  the  diaphragm.  This  was  taken  from  tlie 
body  of  an  aged  clergyman,  of  whom  it  was  said  that  he  had  never  had  a 
day's  illness,  nor  any  symptom  to  draw  attention  to  the  tumor,  until  two 
or  three  days  before  his  death.  He  had  been  a  great  walker,  and  was 
well  known  in  his  neighborhood  by  a  peculiarity  of  gait,  as  if  from  spinal 
curvature. 

Tlie  symptoms  which  in  other  cases  have  presented  themselves  have 
been  occasionally,  but  rarely,  pain  in  the  lumbar  region  and  retraction  of 
the  testicle  as  if  from  stone,  though  no  stone  was  present.  Tlie  more 
serious  results  of  uraemia  do  not  occur  so  long  as  the  other  kidney  is 
healthy,  though  repeated  vomiting,  whether  arising  in  this  or  otherwise, 
has  been  known,  as  also  has  an  urinous  smell  from  the  skin,  the  result 
of  absorption  from  the  cyst  and  cutaneous  excretion.  Hydronephrosis 
may  cause  death  by  discharge  through  the  bowel,  as  in  a  case  already  re- 
ferred to,  or  by  rupture  in  the  peritoneum,  with  consequent  peritonitis 
and  collapse,^  But  the  greatest  dangers  which  hydronephrosis  entails 
are  in  the  surgical  procedures  which  it  suggests,  chiefly  by  its  deceptive 
resemblance  to  ovarian  disease.  In  the  collection  of  cases  I  liave  referred 
to  are  four  in  which  death  was  caused  by  attempted  ovariotomy  ;  four  in 
which  it  followed  upon  tapping,  which,  in  two  instances,  was  performed 
in  the  belief  that  the  cyst  was  ovarian. 

If  hydronephrosis  of  one  kidney  be  accompanied  with  disease  of  the 
other,*  as  in  an  instance  in  which  the  dilatation  on  one  side,  the  result 
of  calculus,  was  conjoined  with  obstruction  by  calculus  of  the  opposite 
ureter,  fatal  suppression  of  urine  may  ensue;  but  that  tlie  disease  is  not 
one  of  rapid  or  large  mortality  is  evident  from  the  fact  that  about  one- 
third  of  the  patients  that  present  themselves  die  of  causes  unconnected 

•  Dr.  Fai-re,  Lancet,  1861,  vol.  ii.  p.  472. 

'  Gintrac,  Sydenham  Societies  Retrospect,  1867  and  1868,  p.  175. 

^  Mr.  J.  Thompson,  Path.  Trans,  vol.  xiii.  p.  128. 

■•  Rayer,  vol.  iii.  p.  490. 


lOG  HYDKONEPHROSIS    AND    PYONEPHROSIS. 

with  it.     The  annexed  abstract  ^ives  the  causes  of  death  in  twenty-eight 
cases  in  which  they  were  explicitly  stated. 

Causes  of  Death  in  twenty-eight  cases  of  Single  Hydronephrosis. 

Imperforate  anus, 1 

Suppression  of  urine,       .........  1 

Ura?mia, 1 

Yoniitinj;,  ...........  1 

Diarrhoea, 1 

Wasting, 1 

Dyspnoja,  etc.,  from  pressure  of  cj'st,    ......  1 

Peritonitis  from  perforation  of  cyst, 1 

Discharge  of  cyst  into  rectum,        .......  1 

Attempted  ovariotomy,   .........  4 

Results  of  tapping, 4 

Suppuration  in  kidney  after  operation  in  bladder,         ...  1 

Accidental  injurj'  unconnected  with  renal  state,  ...  3 

Disease  unconnected  with  renal  state,   ......  7 

28 

The  range  of  duration  of  single  hydronephrosis  is,  as  must  have  been 
already  inferred,  nearly  as  wide  as  that  of  human  life.  Of  eight  cases  in 
whieh  the  disorder  was  apparently  congenital,  death  occurred  at  birth  in 
one;  during  the  first  year  in  four;  in  one  at  the  age  of  eight;  in  one  at 
twenty-two;  in  one  at  thirty-two.  Of  twelve  cases  in  which  the  disorder 
was  acquired  subsequent  to  birth,  the  time  between  the  first  recorded 
symptom  and  death,  often  an  obviously  insufficient  expression  of  the 
duration  of  the  disease,  was  in  one  case  "a  few  days; "  in  two  a  year;  in 
four  between  one  year  and  four  years;  in  two  between  four  years  and  ten; 
in  one  ''many"  years;  in  one  thirty-two  years;  in  one  forty-two  years. 

Pyonephrosis  is  dilatation  plus  inflammation  of  the  pelvis;  hydrone- 
phrosis, dilatation  without  inflammation.  The  dilatation  may  come  first, 
and  the  inflammation  afterwards,  as  in  the  ordinary  occurrence  of  a 
hydronephrotic  cavity  becoming  the  seat  of  suppuration,  either  as  the 
result  of  tapi)ing  or  spontaneously,  in  which  case  hydronephrosis  and 
pyonephrosis  are  but  the  earlier  and  later  stages  of  tlie  same  disease.  Or 
the  inflammation  may  precede  or  accompany  the  dilatation,  as  when  a 
stone  sets  up  pyelitis,  and  subsequently,  or  at  the  same  time,  obstructs 
the  exit.  In  this  case  we  have  pyonephrosis  ab  initio,  independently  of 
hydronephrosis. 

The  symptoms  of  pyonephrosis  are  more  urgent,  its  course  more  rapid, 
and  death  more  often  its  direct  result,  than  is  the  case  with  hydrone- 
i:)hrosis.  It  is  due  in  a  larger  proportion  of  cases  to  calculus  (see  p.  96), 
a  loose  body  within  the  urinary  cavity  being  suited  to  cause  irritation  as 
well  as  obstruction. 

With  pyonephrosis  the  symptoms  of  suppuration,  whether  with  the 
discharge  of  pus  or  of  its  retention,  are  superadded  to  tiiose  of  iiydro- 
nephrosis.  Lardaceous  disease  is  common  as  a  result  of  the  chronic  dis- 
cbarge, while  in  other  cases  the  patients  have  become  hectic  and  sunk 
without  this  adjunct.  In  other  instances  there  have  been  rigors,  ^vith 
the  intermittent  fever  of  septic  or  purulent  absorption,  not,  however, 
going  so  far  as  the  establishment  of  pyaemia  or  secondary  abscesses.  The 
suppurative  process  sometimes  extends  beyond  tlie  kidney  and  penetrates 
the  bowel,  usually  the  descending  colon,  the  affected  kidney  being  the 
left;  and  it  has  been   known    to  extend  backwards  and  cause  erosion  of 


HYDRONEPHROSIS    AND    PYONEPHROSIS.  107 

the  spine,  as  in  an  instance  within  my  own  experience,  where  a  large  col- 
lection of  pus  in  connection  with  a  calculus  was  in  contact  with  the  de- 
nuded transverse  processes  of  the  second  and  third  lumbar  vertebrae.  No 
paraplegic  symptoms  were  noted,  but  it  was  obvious  that,  with  a  little 
further  extension  the  cord  would  have  been  involved.  Further  particu- 
lars as  to  the  extension  of  suppuration  of  renal  origin  will  be  found  in 
the  chapter  on  *'  Perinephritis." 

In  treating  hydronephrosis  it  is  necessary  to  bear  in  mind  its  slow  pro- 
gress and  small  mortality.  Produced,  as  the  secretion  is,  with  less  force 
than  that  of  ovarian  cysts,  it  is  more  easily  arrested  by  the  pressure  it 
naturally  encounters;  the  tendency  to  increase  is  smaller,  and  the  need 
for  interference  less  imperative.  The  spontaneous  occurrence  of  discharge 
by  the  ureter  so  frequently  noted,  and  the  almost  invariable  fact  that  with 
hydronephrosis  this  channel  is  only  imperfectly  closed,  afford  much  en- 
couragement to  the  use  of  friction  and  pressure.  As  long  ago  as  the  year 
1837,'  it  was  put  on  record  that  a  tumor  in  the  abdomen  of  an  infant, 
afterwards  found  to  have  been  formed  chiefly  by  a  great  dilatation  of  the 
ureter,  altered  in  size  when  rubbed,  the  bladder  at  the  same  time  swelling 
under  the  hand. 

Dr.  Broadbent*  related  at  the  Pathological  Society  the  case  of  a  large 
double  hydronephrosis  of  congenital  origin  which  completely  subsided, 
with  profuse  discharge  of  urine,  under  friction  with  the  ointment  of 
iodide  of  potassium,  and  judiciously  infers  that  the  result  was  due  rather 
to  the  friction  than  the  ointment.  Dr.  Eoberts  completely  emptied  a 
unilateral  cyst  of  this  nature  in  a  child  by  diligent  manipulation  every 
•other  morning  with  a  lubricating  ointment;  and  it  is  an  obvious  sug- 
gestion that  re-accumulation  might  be  prevented  by  a  suitable  pad  secured 
by  a  bandage  or  truss.  When  the  cyst  has  become  so  large,  as  in  Mr. 
Glass's  case,  as  to  encroach  upon  the  organs  of  respiration,  or  otherwise 
cause  dangerous  pressure,  or,  as  in  one  recorded  by  Mr.  Thompson,  to  be 
painful  when  distended,  it  may  be  necessary  to  draw  off  the  fluid.  Most 
•of  the  cases  in  which  this  has  been  done  have  been  anterior  to  the  aspi- 
rator, and  the  results  less  satisfactory  than  would  probably  now  be  the 
case.  I  have  before  me  the  particulars  of  fourteen  cases  in  which  a  renal 
•cyst,  holding  an  aqueous  or  purulent  fluid,  was  tapped  once  or  repeatedly: 
in  six  a  fatal  result  was  immediately  due  to  this  operation,  in  four  by  way 
■of  escape  and  peritonitis;  in  one  case  death  occurred  only  after  fifteen 
years'  discharge  through  a  fistulous  opening  tlius  established;  in  seven, 
the  operation  was  unattended  with  injurious  results.  Tapping  Avas  exe- 
cuted often  on  a  false  hypothesis:  in  one  instance,  as  Avas  suj)posed,  for 
ascites;  in  one  for  hydatid  of  the  liver;  in  four  for  ovarian  disease.  I 
presume,  however,  that,  when  the  organic  site  of  the  disease  is  clear,  the 
ureter  closed,  and  the  accumulation  purulent,  it  would  be  riglit  to  relieve 
it  from  the  loin,  notwithstanding  the  results  which  have  attended  abdo- 
minal tapping.  The  proper  course  would  probably  be  to  aspirate  from 
behind,  post-peri toneally,  after  having  found  the  matter  by  tentative 
puncture  with  a  capillary  tube.  Dr.  Coghill  ta]>ped^  a  hydronephrotic 
cyst  from  the  loin  behind  the  peritoneum,  with  the  discharge  of  over 
four  pints  of  aqueous  fluid.     The  patient,  as  I  learn  from  Dr.  Coghill, 


'  Mr.  Thurnam,  Land.  Med.  Oaz.  vol.  xx.  (1837)  p.  717.    Quoted  by  Mr  Morris 
Med.-Chir.  Trans,  vol.  lix.  ' 


«  Path.  Trans,  vol.  xvi.  p.  164. 

^  Edin.  Med.  Journ.  Feb.,  1875,  p.  747. 


108  HYDRONEPHROSIS    AND    PYONEPHROSIS. 

was  apparently  cured  by  the  operation,  for  she  is  now  (1882)  alive  and 
well. 

The  question  next  arises  as  to  excision  of  the  cyst,  whether  hydro-  or 
pyonephrotic.  This  has  been  performed  in  a  considerable  number  of 
cases,  some  of  which  were  known  to  be  renal,  many  supposed  to  be 
ovarian.  We  are  indebted  to  Mr.  Harker  '  for  valuable  tabular  statements, 
which  represent  the  published  experience  on  tliis  subject  up  to  March, 
1881.  Mr.  Barker  has  collected  fourteen  instances  in  which  renal  cysts 
or  dilatations  have  been  removed:  eiglit  by  abdominal  section,  with  five 
deaths,  and  three  recoveries;  six  from  the  loin,  with  four  deaths  and 
two  recoveries.*  In  five  of  the  cases  of  abdominal  section  the 
tumor  was  thought  to  be  ovarian;  three  cases  were  operated  on  know- 
ingly as  hydronephrosis,  all  by  abdominal  section,  with  one  death;  three 
were  operated  on  knowingly  as  pyonephrosis,  all  by  lumbar  section,  with 
two  deaths.  Thus  it  would  appear,  so  far,  that  the  mortality  attending 
the  removal  of  diagnosed  renal  cysts  is  fifty  per  cent.  The  condition 
found  in  the  fourteen  cases  referred  to  was  described  as  hydronephrosis 
in  three,  with  one  of  which  sarcoma  Avas  conjoined;  as  pyonephrosis  in 
two.  There  were  seven  in  which  dilatation  and  sacculation  were  found, 
but  which  cannot  be  definitely  ascribed  to  one  category  or  the  other, 
though  it  is  probable,  from  the  frequency  of  calculus  among  them,  that 
most  would  have  fallen  under  the  description  of  pyonephrosis.  Four 
cases  were  of  renal  cysts  of  uncertain  character. 

As  might  be  expected,  the  incision  of  renal  cysts  presents  itself  as 
more  successful  wlien  performed  intentionally  than  by  mistake;  but,  in 
any  circumstances,  the  operation  involves  too  much  risk  to  be  recom- 
mended unless  more  than  ordinary  danger  be  involved  in  the  progi'ess  of 
the  disease.  Hydronephrosis,  chronic  and  comparatively  harmless  as  it 
is,  can  scarcely  justify  such  hazards  as  are  properly  incurred  in  dealing 
with  an  ovarian  cyst;  and  as  compared  with  ovariotomy,  it  is  probable 
that  the  dangers  of  removing  a  large  reiuil  cyst  through  tlie  abdomen 
will  always  be  the  greater.  But  when  the  collection  is  purulent,  from 
stone  or  otherwise,  danger  may  threaten,  whether  by  exhaustion  or  ex- 
tension, which  may  warrant  the  operation,  thougli,  as  far  as  we  yet 
know,  those  are  greater  than  are  incurred  when  aqueous  distention  is  in 
question. 

I  have  recently  been  informed  by  my  colleague,  Dr.  Barlow,  of  a 
successful  excision,  in  a  case  of  pyonephrosis  under  his  care,  performed 
by  Mr.  Cowper.  The  patient,  a  girl  of  sixteen,  in  good  general  health, 
had  lumbar  pain,  passed  highly  purulent  urine,  with  much  frequency, 
and  displayed  a  tumor  in  the  right  renal  region,  Avhich  was  traversed  by 
bowel.  Nephrectomy  was  performed  tlirough  the  loin,  with  the  removal 
of  a  thin-walled  suppurating  cyst  which  represented  the  kidney.  There 
was  no  sign  of  tubercle  or  caseation  about  it,  nor  any  evidence  as  to  the 
cause  of  the  dilatation.  The  patient  had  perfectly  recovered  by  the  fol- 
lowing August. 

'  Med.-Chir.  Trans,  vols.  Ixiii.  and  Ixiv. 

*  See  cases  by  Czerny,  Thornton,  Couper,  Barker,  and  Lange.  See  paper  by 
Barker,  MecL-Chir.  Trans,  vol.  Ixiv. 


CHAPTER    X. 

CYSTIC   DISEASE   OF   THE   KIDNEY. 

Cysts  as  closed  cavities  witliin  the  renal  substance  are  sufficiently  dis- 
tinct from  the  cystiform  dilatation  of  the  hollow  organ  to  which  the  term 
hydronephrosis  is  given.  And  it  must  be  needless  to  refer  to  the  essen- 
tial differences  between  the  cysts  in  question,  which  are  for  the  most 
part  transformations  of  the  proper  elements  of  the  organ  and  those  of 
parasitic  origin,  which  will  find  consideration  elsewhere. 

For  practical  purposes  renal  cysts  may  be  thus  classed: 

1.  Minute  cysts  which  occur  as  part  of  some  other  form  of  renal 
disease,  more  especially  the  interstitial,  and  occasionally  present  them- 
selves in  kidneys  ostensibly  healthy. 

2.  Large  and  numerous  cysts  which  give  rise  to  great  increase  of 
size  of  the  affected  organs;  these  mav  be  congenital  or  acquired  after 
birth. 

3.  Large  cysts  which  are  solitary,  or  only  accompanied  by  a  few  others, 
usually  of  minute  size.  These  may  be  similar  in  nature  to  those  pre- 
viously mentioned,  or  may  be  connected  witii  malignant  or  other  dis- 
ease. 

4.  To  these  must  be  added  cysts  which  may  be  termed  i)arane2ihric, 
which  involve  or  impinge  upon  the  kidney  from  the  outside. 

The  Large  Cystic  Kidney  as  a  Disease  of  Extra-uterine  Life. 

I  do  not  now  propose  to  deal  with  the  renal  cysts,  usually  of  small 
aize,  though  often  in  considerable  numbers,  which  present  themselves  as 
the  concomitants  of  other  renal  changes,  to  which  they  play  only  a  sec- 
ondary part;  these  have  found  mention  in  connection  with  the  types  of 
renal  disease  to  which  they  belong:  I  refer  at  present  only  to  the  large 
cystic  kidney,  in  which  the  vesiculation  transcends  all  other  changes,  and 
produces  such  increase  of  bulk  that  the  organs  may  fairly  be  considered 
as  abdominal  tumors. 

The  kidneys  are  transformed  into  collections  of  cysts  so  completely, 
in  well-marked  cases,  that  it  is  diflBcult  to  discern  with  the  naked  eye 
any  remnants  of  the  proper  tissue,  though  with  the  microscope  this  is 
always  to  be  abundantly  found,  however  its  ordinary  semblance  may  be 
destroyed  by  extension  and  distortion.  Tiie  increase  of  bulk  is  usually 
great,  though  the  renal  shape  is  more  or  less  preserved,  as  if  the  addition 
of  substance  were  distributed  with  some  uniformity.  Such  kidneys 
often  measure  ten  inches  in  length,  and  weigh  two  or  three  pounds 
each.  Two  at  St.  George's  Hospital,  described  by  Dr.  Whipham  in  the 
twenty-first  volume  of  the  ''  Pathological  Transactions,"  weighed  eighty- 
one  and  three-quarter  ounces,  another  pair  from  a  patient  under  the 
late  Dr.  Page  weighed  six  pounds  ten   ounces,  while  the  maximum  of 


110  CYSTIC    DISEASE    OF    THE    KIDNEY. 

balk  was  reached  in  a  case  placed  on  record  by  Dr.  Hare,'  in  which  the 


'H\ 


t 


7J 


^iiiiii'' 


Large  cystic  kidney,  one  of  a  pair  which  weighed  eighty-one  and  three-quarter  ounces,  referred 
to  on  preceding  page.  (From  a  patient  in  St.  George's  Hospital,  under  Dr.  Wadham,  reported  by 
Dr.  Whipham.)    "  Path.  Trans."  vol.  xxi.  p.  245. 

'  This  remarkable  case  is  recorded  by  Dr.  Hare  in  the  Path.  Trans,  for  1850- 
51.  By  a  printer's  error  it  is  stated  that  "  some  of  the  cysts  contained  hydatids." 
I  have  Dr.  Hare's  authority  for  stating  that  for  some  should  be  read  none.  The 
case  is  therefore  unequivocal,  and  is  of  great  interest. 


CYSTIC    DISEASE    OF    THE    KIDNEY. 


Ill 


left  kidney  weighed  sixteen  pounds  and  measni-ed  fifteen  'and  a  quarter 
inches  in  "length,  while  the  right  was  enlarged,  but  only  to  double  its 
natural  size. 

The  cortical  substance,  and  to  a  less  extent  the  cones,  are  Tcplaccd  by 
cysts  which  vary  in  size  from  the  smallest  distinguishable  by  the  naked 
eye — while  smaller  still  ai-e  shown  by  the  microscope — to  the  bulk  of  wal- 
nuts as  is  common,  or  much  beyond  this.  In  Dr.  Hare's  case,  the  larg- 
est cavity  held  more  than  half  a  pint.  The  cysts  protrnde  from  the 
surface  as  circular  bosses,  raising  the  capsule,  which,  together  with  the 
cyst-wall,  is  so  trans^iarent  that  the  variously  colored  contents  can  be 
seen  from  without.  The  external  appearance  roughly  resembles  that  of 
a  water-worn  mass  of  conglomerate  or  pudding-stone,  the  prominent 
pebbles  representing  the 
cysts.  On  section,  the 
globular  or  ovoid  cavities 
are  seen  to  be  crowded  to- 
gether and  altered  in  shape 
by  apposition,  nothing  be- 
ing easily  recognizable  of 
the  renal  tissue,  except  here 
and  there  the  remnant  of 
a  cone.  These  structures, 
however,  as  already  stated, 
are  not  exem  pt  f  rom  the  mor- 
bid transformation,  though 
less  alfocted  than  the  cor- 
tex. Within  them  cysts  are 
often  to  be  seen,  though 
smaller  and  less  numerous 
than  elsewhere.  The  cysts, 
wherever  found,  appear  to 
be  lined  with  a  translucent 
membrane,  which  is  smootli, 
excejit  that  in  the  larger 
cavities  it  may  display  shal- 
low folds  or  creases.  Their 
contents  are  various  in  color 
and  kind ;  they  are  generally 
pale  or  deep-yellow,  and 
highly  albuminous ;  often 
viscid,  treacly,  or  even  col- 
loid; they  are  sometimes  purplish,  variously  blood-tinged,  purulent,  or 
caseous;  epithelial  cells  and  renal  tubes  have  been  found  in  tlicm,  some- 
times uric  acid,  cholesterin,  or  triple  phosphate.  The  pelvis  and  ureter 
are  commonly  free  from  dilatation,  though  this  alteration  to  a  sliglit  extent 
has  in  some  cases  been  recorded.  I  have  occasionally  noticed  that  the 
pelvis  has  been  stretched  with  the  dimensions  of  the  organ,  but  under- 
gone no  increase  of  capacity. 

Both  kidneys  are  usually  affected.  I  find  that  among  twenty-six 
cases  of  which  the  morbid  appearances  are  fully  recorded,  there  was  only 
one  in  which  the  disease  was  not  obviously  bilateral,  though  often  more 
advanced  on  one  side  than  the  other.  In  the  single  exception,*  many 
of  the  tubes  of  the  apparently  unaffected  kidney  were  found  to  be  de- 


Cyst  from  large  cystic  kidney,  showing  its  epithelial 
lining. 


1  Dr.  Conway  Evans,  Path.  Trans,  vol.  v.  i>.  183. 


112 


CYSTIC    DISEASE    OF    THE    KIDNEY. 


nuded  and  dilated,  changes  which,  as  will  be  presently  seen,  are  part  of 
the  cyst-forming  process. 

I  have  made  translucent  sections  of  as  many  large  cystic  kidneys  as 
I  have  been  able  to  obtain,  including  fresii  specimens,  and  others  that  have 
been  preserved  in  spirit,  some  as  taken  from  the  body,  and  some  after 
minute  injection  of  the  arteries;  the  results  are  as  follows:  The  cysts  are 
globular,  ovoid,  or  somewhat  irregular  closed  cavities  which  range  u])- 
wards  in  size  fi'om  about  the  normal  diameter  of  tubes  to  sizes  which  are 
beyond  the  comprehension  of  the  microscope.  They  lie  for  the  most 
part  among  the  convoluted  tubes,  but  occasionally  among  the  straight, 
closely  surrounded,  wherever  they  be,  by  the  proper  structure  of  the 
organ.  The  boundaries  of  the  cysts  or  cavities  often  appear  to  be  formed 
only  of  exposed  and  condensed   renal  tissue,  though   in  some  instances 


Cyst  in  large  cystic  kidney  filled  with  detached,  crumpled,  and  denuded  tubes. 


this  is  seen  to  be  lined  by  a  delicate  layer  of  epithelium,  a  basement 
membrane  beneath  it  being  a  matter  rather  of  inference  than  demonstra- 
tion. The  epithelial  cells  are  of  small  size,  but  mostly  solid  figure,  such 
as  might  have  been  derived  with  little  alteration  from  the  tubes.  Occa- 
sionally they  are  flat.  The  thin,  almost  imaginary,  walls  of  the  cysts  are 
in  marked  contrast  with  the  thick  coats  of  the  neighljoring  blood-vessels. 
The  C3'Sts,  as  seen  under  the  microscope  and  in  section,  are  generally 
empty,  especially  those  of  large  size,  while  the  smaller  are  sometimes 
filled  W'ith  a  translucent,  structureless  material,  which  hardens  in  spirit 
or  chromic  acid,  so  as  to  retain  its  place  in  thin  sections.  In  three  S])eci- 
mens  I  have  found  contents  which  were  at  first  sight  i)uzzling,  but  which 
I  think  can  be  accounted  for  without  improbability.  The  cysts  or  cavi- 
ties I  refer  to,  which  are  comparatively  seldom  met  with,  are  of  small 


CYSTIC    DISEASE    OF    THE    KIDNEY.  113 

size,  perhaps  four  or  five  times  the  diameter  of  a  Malpighian  body,  and 
contain  tubes  detached  from  their  surroundings,  and  either  little  altered 
or,  as  in  the  woodcut  (p.  112),  crumpled  and  denuded.  I  liave  seen  such 
tubes  as  in  the  illustration,  comprised  within  a  regular  cyst,  or  in  other 
cases  sticking  raggedly  out  of  the  walls  of  a  broken  cavity.  The  appear- 
ance suggests  that  tlie  cavity  in  each  case  has  resulted  from  a  local  de- 
struction of  tissue  rather  than  by  mere  distention  of  any  existing  struc- 
ture ;  the  frequent  absence  of  lining  membrane  corroborates  this  view. 
Supposiiig  a  tube  to  burst  in  the  process  of  distention,  it  might  give  rise 
to  such  appearances  as  have  been  described — a  somewhat  indefinite  cavity 
would  be  formed,  into  which  surrounding  tubes  might  protrude  or  fall. 
Witii  time  the  cavity  might  acquire,  as  in  the  woodcut,  a  regularly  cystic 
outline. 

The  tubes  and  Malpighian  bodies  lie,  as  has  been  intimated,  in  close 
apposition  to  the  cysts ;  the  Malphighian  bodies  are  often  close  to  the 
cavity,  and  even  protrude  into  it,  as  if  some  process  of  destruction  had 
worn  away  the  less  resistant  parts  of  the  glandular  structure  ;  but  they 
are  clearly  normal  in  character  and  position,  as  if  any  association  they 
miglit  present  with  the  cavities  were  accidental.  The  most  noteworthy 
condition  of  the  tubes  about  the  cysts  and  in  cystic  kidneys  elsewhere  is 
irregular  dilatation.  This  may  be  more  or  less  general,  so  as  to  give  to 
the  section  an  almost  honeycombed  appearance,  or  limited  to  certain 
tubes,  whether  convoluted  or  straight,  which  are  conspicuous  by  their 
solitary  enlargement,  and  are  often  densely  plugged  with  epithelium  or 
blood.  These  are  often  of  such  size — many  times  the  common  diameter 
of  tubes — that,  when  seen  in  transverse  section,  it  requires  care  to  deter- 
mine whether  they  be  tubes  or  cysts.  A  longitudinal  view  is  of  course 
conclusive,  but  Avhen  this  cannot  be  obtained,  it  is  often  impossible  to  say 
whether  one  is  looking  at  a  tube  or  a  cyst,  so  close  may  the  resemblance 
be. 

There  is  often  about  the  cysts  and  the  kidney  containing  them  much 
hypernucleation  and  fibrosis  ;  usually  not  general,  as  with  the  granular 
kidney,  but  scattered  or  partially  distributed.  The  blood-vessels  of  the 
organ  appear,  both  in  injected  and  uninjected  specimens,  to  be,  like  the 
Malpighian  bodies,  natural;  they  have  no  special  relation  to  the  cysts, 
though  they  often  pursue  an  uninterrupted  course  riglit  up  to  the  edge 
of  the  cystic  cavity,  as  if  this  were  a  mere  broken  hole,  without  any  se])a- 
ration  between  the  surrounding  tissue  and  its  cavity.  Less  frequently 
capillaries  can  be  traced  in  circular  arrangement  around  the  slender 
cyst- wall. 

The  cysts  in  question,  unaccompanied  as  they  are  Avith  any  formation 
foreign  to  the  kidney,  are  necessarily  but  an  alteration  of  it,  either  by 
destruction  of  its  tissue  or  transformation  of  its  elements.  I  have  shown 
reason  to  suppose  that  some  at  least  are  attended  with  destruction  of 
tissue,  but  the  majority  are  obviously  the  results  of  transformation.  I 
have  seen  nothing  to  justify  a  view  which  has  been  advanced,  that  tiiey 
are  excessive  and  peculiar  overgrowths  of  the  epithelia.  I  have  never 
seen  a  cyst  within  a  tube,  however  often  they  api)ear  to  replace  tubes. 
Tiie  choice  lies  between  transformation  of  the  tubes  and  of  the  Malpi- 
ghian bodies.  With  regard  to  the  Malpighian  bodies,  it  is  beyond  doubt 
that  these  are  sometimes  dilated  as  the  result  of  interstitial  disease, 
though  not  so  far  as  I  have  been  able  to  make  out,  to  much  beyond 
microscopic  limits.  In  large-cysted  kidneys,  I  have  never  been  able 
to  satisfy  myself  that  any  of  the  cvsts  had  this  origin.  The  Mal- 
8 


114  CVSTIO    DISEASE    OF    THE    KIDNEY. 

pighian  bodies  are  evidently  unconnected  with  the  cysts,  though  often  in 
apposition  to  them,  and  display  no  change,  save  tiiat  rarely  a  capsule 
may  be  a  little  dihited,  as  is  so  often  seen  in  other  forms  of  renal  disease. 
The  presence  of  cysts  within  the  cones,  where  no  Malpighian  bodies  are, 
is  evidence  that  in  this  situation  at  least  they  have  no  such  origin. 
There  is  a  large  cystic  kidney  at  the  College  of  Surgeons  (1,902a),  of 
which  the  cysts  are  stated  in  tlie  catalogue  to  be  formed  by  enlargement 
of  the  Malpighian  capsules,  within  which  the  Malpighian  tufts  were  seen. 
By  the  courtesy  of  Professor  Flower  I  was  enabled  to  examine  this  prepara- 
tion. The  Malpighian  bodies  were  generally  natural ;  the  cysts  clearly 
had  no  association  with  them  except  that  of  accidental  contiguity;  in 
some  cases  the  Malpighian  body  lay  in  tlie  wall  of  the  cyst,  clearly  sepa- 
rated from  its  cavity  by  the  undilated  Malpighian  capsule,  virtually  ex- 
ternal to  the  morbid  process  however  near  to  it.  It  cannot  be  doubted 
that  the  cysts  are,  as  a  rule,  altered  tubes;  whatever  uncertainty  there  is, 
is  only  as  to  the  manner  in  which  the  change  has  been  wrought.  The 
epithelial  lining  of  the  cysts,  the  tenuity  of  their  walls  and  their  resem- 
blance to  the  walls  of  tubes,  the  presence  of  the  cysts  wherever  tubes  are 
found,  the  frequent  arrangement  of  these  morbid  formations  in  line,  and 
their  containing  urinary  constituents,  together  furnish  apparently  con- 
clusive evidence.  The  mode  of  their  formation  can  scarcely  be  but  by 
constriction,  closure,  and  final  obliteration  of  the  tubes  at  certain  points 
between  which  secretion  continues,  but  cannot  escape.  The  only  appear- 
ances suggestive  of  obstruction  wliich  such  kidneys  present  are  ordinary 
tubal  distention,  not  to  be  distinguished  from  that  of  ordinary  tubal 
nephritis,  and,  what  is  more  constantly  present — indeed,  it  occurs  Avith- 
out  exception,  as  far  as  I  have  seen — inter  tubal  overgrowth,  Avith  conse- 
quent constriction  of  the  tubes;  if  there  be  any  other  cause  of  obstruction 
it  is  either  transient  in  its  nature,  or  not  such  as  to  present  itself  to 
microscopic  examination. 

To  complete  the  pathology  of  the  cystic  kidney  by  reference  to  associ- 
ated changes,  cysts,  roughly  speaking  of  a  similar  nature,  have  been  found 
in  the  liver  and  spleen,  though  so  infrequently  that  it  may  be  doubted 
Avhether  the  connection  is  more  than  accidental.  Special  attention  has 
been  drawn  to  this  concurrence  in  the  ''  Pathological  'J'ransactions,"  by 
Dr.  Bristowe  in  the  first  place,  and  later  by  Drs.  Wilks  and  Pye  Smith, 
and  four  exam})les  there  recorded,  in  which  the  liver  was  cystic  together 
Avith  one  or  both  kidneys,  and  one  in  Avhicli  the  spleen  was  atfected  to- 
gether Avith  the  kidneys.  Including  these,  there  Avere  among  the  total 
of  thirty-three  cases  of  the  cystic  kidney,  five  in  Avhich  the  liver  Avas  thus 
affected,  one  in  Avhich  the  spleen  Avas  affected;  but  it  is  not  probable  that 
cysts  in  other  organs  actually  concur  Avitli  those  in  the  kidney  in  nearly 
so  large  a  proportion  as  this  represents;  for  the  cases  of  concurrence  have 
been  especially  sought  for  and  brought  together.  The  origin  of  the  cysts 
in  the  renal  tubes,  of  which  no  doubt  can  be  entertained,  is  enough  to 
dissociate  their  nature  from  such  as  arise  in  organs  which,  like  the  spleen, 
have  no  secreting  ducts,  or,  like  the  liver  ducts,  Avhich  are  so  dissimilar 
to  those  of  the  kidney  that  they  can  scarcely  be  supposed  to  share  the 
same  diseases.  The  cysts  in  the  liver  have  generally  been  small,  seldom 
numerous;  they  have  been  supposed  by  Dr.  Lionel  Beale'  to  originate  in 
a  change  in  the  hepatic  cells,  Avhich  Dr.  Pye  Smith  defines  as  vacuola- 

'  Dr.  Lionel  Beale,  examination  of  case  recorded  by  Dr.  Bristowe,  Path.  Trans. 
vol.  vii.  p.  234.     Dr.  Pye  Smith,  Path.  Trans,  vol.  xxxii.  p.  112. 


i 


CYSTIC    DISEASE    OF    THE    KIDNEY.  115 

tion.  It  is  sufficiently  clear  that  the  C3'Sts  do  not  depend  on  any  new 
growths  common  to  several  organs,  but  are  modifications  of  the  organs 
themselves,  probably  different  in  each  situation,  and  connected  remotely, 
if  at  all. 

To  complete  as  much  of  the  morbid  anatomy  of  the  disease  as  may  be 
considered  apart  from  its  progress  and  termination,  the  heart  has  in  many 
cases  been  found  to  be  hypertrophied,  as  with  the  granular  kidney.  In 
three  instances  which  occurred  at  St,  George's  Hospital,  this  organ, 
which  was  enlarged  chiefly  in  the  left  ventricle,  and  without  the  occur- 
rence of  valvular  disease,  though  in  one  of  them  the  aorta  was  noted  as 
atheromatous,  weighed  respectively  twenty-three  ounces,  twenty-two  and 
a  quarter  ounces,  and  nineteen  ounces.  The  state  of  the  heart,  there- 
fore, is  much  what  it  would  have  been  had  the  kidneys  exhibited  the 
ordinary  form  of  granular  degeneration  instead  of  cystic  transformation 
and  enlargement.  The  whole  morbid  anatomy  of  the  disease  points  to 
the  inference  that,  although  it  is  possible  that  in  some  cases  the  cystic 
change  may  be  due  to  obstruction  by  tubal  nephritis,  yet,  as  a  rule,  it  is 
due  to  a  form,  perhaps  a  peculiar  form,  of  interstitial  fibrosis.  Evidences 
of  this  overgrowth  are  always  abundantly  present,  and  appear  sufficient 
to  account  for  the  cystic  conversion,  while  no  distinction  in  kind,  how- 
ever much  in  degree,  is  to  be  recognized  between  the  small  and  scattered 
cysts,  so  common  in  the  contracted  granular  kidney,  and  the  gigantic  and 
innumerable  chambers  which  produce  the  cystic  enlargement. 

The  clinical  outline  Avliich  follows  is  chiefly  founded  upon  an  analysis 
of  thirty-three  cases,  ten  of  which  have  been  obtained  from  the  records 
of  St.  George's  Hospital,  two  relating  to  patients  of  my  own  in  that  in- 
stitution. The  rest  were  obtained  from  other  hospitals  and  pathological 
collections,  and  various  publications. 

The  subjects  of  the  enlarged  cystic  kidney  are  more  often  males  than 
females,  in  the  proportion  of  21  to  7,  judging  from  28  cases  which  afford 
information  in  this  particular.  They  are  always  adults  (I  am  not  now 
considering  the  congenital  cystic  kidney,  fatal  about  or  before  birth): 
the  ages  at  death  varied  in  21  cases  from  20  to  98  years.  In  five  in- 
stances death  occurred  between  the  ages  of  20  and  29;  in  one  between  30 
and  39,  in  eleven  between  40  and  49;  in  five  between  50  and  98.  It  thus 
presents  itself  as  an  acquired  chronic  disease  somewhat  resembling  in  its 
incidence  the  granular  kidney.  The  mortality  between  40  and  49  is 
noteworthy  in  this  light;  and  scarcely  less  so  its  early  period  of  fatal 
activity  between  20  and  30,  which  may  correspond  with  those  cases  of 
early  granular  kidney  which  are  due  to  scarlatina  and  the  other  affections 
of  childhood. 

As  with  granular  degeneration,  the  causes  of  cystic  enlargement  are 
obscure,  and  its  beginning  unmarked.  Gout  has  not  presented  itself  in 
the  cases  from  which  I  have  drawn.  Tuberculosis,  generally  in  the  form 
of  phthisis,  was  present  in  five  cases  of  twenty-eight  of  which  details  arc 
given;  not  of  ten  enough  to  indicate  any  pathological  association.  In  two 
cases  the  diseiise  followed  a  blow  or  injury;  in  one  it  was  attributed  to 
cold. 

The  disease,  which  is  usually  latent  until  an  advanced  stage  is  reached, 
not  unfrequently  remains  so  until  revealed  hy  post-mortem  examination; 
this  was  so  in  nine  of  twenty-five  cases  of  which  I  have  histories.  When 
the  disorder  is  declared,  it  is  usually  by  symptoms  which  are  so  nearly 
those  of  the  granular  kidney  that  it  is  only  by  the  presence  of  the  renal 
tumors  that  a  sure  distinction  can  be  m^de.     The  differences  are  chiefly 


116  CYSTIC    DISEASE    OF    THE    KIDNEY. 

these:  With  the  large  cystic  kidney  there  is  almost  no  tendency  to  dropsy, 
while  pain  in  the  loins  is  more  obtrusive,  and  hematuria  more  frequent 
and  profuse,  than  with  the  more  common  form  of  disease.  The  latter 
distinction  is  strongly  marked.  Dropsy,  whether  superficially  or  in  the 
serous  cavities,  appears  to  be  generally  absent.  A  patient  under  my  own 
care  was  said  to  have  had  swelling  of  the  legs,  but  when  Isaw  him  there 
was  none.  The  only  recorded  case  I  have  met  with  in  which  oedema  was 
mentioned,  presumably  as  a  result  of  this  disease,  was  that  of  the  gigantic 
cystic  kidney  recorded  by  Dr.  Hare  (see  p.  110).  In  this  it  is  probable 
that  the  swelling  was  due  more  to  the  mechanical  effect  of  the  tumor 
than  to  the  constitutional  influence  of  the  disease.  The  oedema  was 
most  marked  on  the  side  to  which  the  renal  swelling  was  nearly  limited. 

The  urine  furnishes  the  most  marked  evidence  of  the  presence  of  the 
disease,  though  not  of  its  kind.  It  has  the  characters  which  belong  to 
the  granular  kidney.  It  may  possibly  be  normal,  as  with  the  earlier 
forms  of  this  disorder.  Dr.  Conway  Evans  has  described  an  instance  in 
which  this  secretion  was  natural,  and  the  large  cystic  kidney  found  to 
exist.  But  there  are  few  exceptions  to  the  rule  that,  with  the  advanced 
disease,  it  has  been  found  to  be  albuminous  if  examined,  though  in  many 
cases  the  urine  and  the  disease  have  alike  escaped  notice.  The  albumin 
has  varied  from  a  small  amount  up  to  about  two-thirds.  The  urine  has 
usually  been  pale,  co))ious,  of  low  specific  gravity  (in  one  instance  down 
to  1.005),  and  has  been  found  to  contain  casts,  as  in  a  case  under  my  own 
observation,  of  the  coarse  granular  variety.  It  is  characterized  in  most 
cases  by  the  frequent  admixture  of  blood,  often  so  copiously  as  to  call  for 
styptics.  Of  sixteen  cases  in  which  symptoms  were  present,  hsematuria 
was  prominent  in  eleven.  In  some  it  largely  contributed  to  death  by  the 
exhaustion  it  caused;  in  others  it  gave  trouble  by  the  formation  of  coag- 
ula,  which  were  passed  with  difficulty;  and  in  one  it  helped  to  produce 
suppression  by  the  blocking  with  coaguluni  of  one  ureter.  In  a  few  in- 
stances small  amounts  of  pus  have  been  found. 

The  pathognomonic  feature  of  the  disease  is  the  double  tumor,  a  sign 
generally  unfound  and  unsought  for,  the  observer  being  generally  satisfied 
to  regard  the  case  as  one  of  the  granular  kidnev.  Among  the  general 
characters  of  renal  tumors  (p.  41)  is  to  be  found  an  outline  from  a  case 
recorded  by  Bright.  The  laterally  symmetrical,  though  often  unequal, 
tumors  are  softer  than  solid  renal  growths,  but  do  not  fluctuate.'  Dr. 
Hare's  case,  already  referred  to,  gives  an  instance  of  the  largest  abdomi- 
nal swelling  from  this  cause,  as  of  the  largest  renal  tumor.  The  palpable 
tumefaction  reached  from  the  thorax  to  an  inch  and  a  half  below  the 
spine  of  the  ilium,  and  from  the  loin  to  within  an  inch  of  the  median 
line.  Tins  bulky  mass  presented  in  the  abdomen  in  the  guise  of  two 
tumors  on  the  same  side,  with  bowel  between;  but  since  both  could  be 
moved  together  from  the  loins,  it  was  decided,  Avith  the  help  of  Dr. 
Brigiit,  that  there  was  but  one,  and  that  kidney.  The  kidney  on  the 
other  side,  it  may  be  observed,  was  not  affected  so  as  to  be  appreciable 
from  without. 

The  general  aspect  of  the  patient,  his  sallowness,  his  cardiac  hyper- 
trophy and  his  arterial  tension,  are,  like  the  urine,  all  indicative  of 
chronic  renal  disease,  and  deceptive  as  to  its  nature,  unless,  indeed,  it 
be  held,  as  may  be  the  case,  that  the  cystic  and  the  granular  kidney  are 
varieties  of  the  same  essential  condition.     With  the  advance  of  the  dis- 

'  See  case  recorded  by  Roberts,  3d  edit.  p.  512. 


CYSTIC    DISEASE    OF    THE    KIDNEY,  117 

ease  ursemiii  often  presents  itself  with  gastric  and  cerebral  disturbances, 
obstinate  vomiting,  convulsion,  and  coma.  This  is,  indeed,  the  most 
frequent  cause  of  deatii.  I  noticed  in  one  instance  that  the  body  emitted 
not  the  ordinary  odor  of  uraemia,  such  as  is  usually  produced  by  disease 
of  the  substance  of  the  kidney,  but  a  truly  urinous  smelll,  such  as  more 
often  indicates  retention  of  urine  in  a  cavity,  as  with  obstructive  sup- 
pression, wiiich,  however,  did  not  exist.  In  an  instance  I  have  already 
alluded  to,  under  my  owii  observation,  nearly  complete  suppression  ex- 
isted for  two  days  before  death,  after  which  the  lower  part  of  the  right 
ureter  was  found  to  be  })lugged  with  a  decolorized  clot,  tiie  other  ureter 
and  the  bladder  being  natural.  Death  by  uraemia  is  sometimes  antici- 
pated by  exhaustion  from  iiaematuria,  and  not  seldom  by  bronchitis, 
pneumonia,  or  congestion  of  the  lungs,  with  sudden  and  severe  dyspnoea. 
This  termination  occurred  in  two  cases  in  St.  George's  Hospital,  which 
have  been  placed  on  record  by  Dr.  Whipham.'  As  with  the  granular 
kidney,  cerebral  hemorrhage  has  been  known  to  occur  in  these  cases;  in 
a  case  recorded  by  Dr.  Cliurch  there  was  evidence  of  an  attack  of  this 
nature  three  years  before  death. ^ 

It  is  difficult  to  estimate  the  duration  of  a  disorder  of  which  the  be- 
ginning is  usually  so  indefinite.  It  must  necessarily  be  considerable.  In 
a  case  at  St.  George's  Hospital  the  outset  was  apparently  due  to  a  blow 
seven  years  before  death;  in  another,  at  the  same  institution,  lumbar 
pain  appeared  to  mark  its  beginning  five  years  before  death.  Dr. 
Bright's  patient,  from  wliom  the  outlines  were  taken'  which  have  been 
reproduced,  was  attacked  with  hematuria  two  years  before  death;  Dr. 
Hare's  nine  months  before  death. 

.  It  is  not  necessary  to  refer  to  treatment  further  than  to  say  that  the 
uremic  symptoms  must  be  met  in  the  ways  detailed  in  connection  with 
granular  degenei'ation. 

Congenital  Cystic  Transformation  of  the  Kidneys. 

The  kidneys  of  the  foetus  sometimes  undergo  a  cystic  transformation 
similar  to  that  which  belongs  to  extra-uterine  life,  though  it  is  sufficiently 
clear  from  the  age  at  which  the  later  disorder  declares  itself,  that  is  not 
a  continuation  of  a  congenital  condition,  but  an  acquirement  of  advanc- 
ing years.  The  foBtal  condition  is  of  little  interest  to  tlie  physician,  how- 
ever important  to  the  i)athologist  as  showing  typically  and  simply  the 
results  of  obstruction.  The  disorder  has  not  come  within  my  experience, 
and  I  have  nothing  to  adil  to  what  is  generally  known.  Tlie  kidneys 
may  have  become  swollen  in  utcro  so  as  to  equal  or  exceed  the  bulk  of 
the  healthy  kidney  of  the  adult,  by  a  cystic  transformation  which  closely 
resembles  that  which  has  been  already  described,  and  is  due  to  absence 
or  obstruction  of  the  urinary  exit.  Th.e  cysts  have  been  found  to  con- 
tain urinary  matters,  and  there  is  a  concurrence  of  evidence  and  proba- 
bility that  they  generally  consist  of  dilated  and  intersected  tubes,  as  those 
of  a  later  date  have  been  shown  to  do.  Sir  W.  Gull "  who  reported  many 
years  ago  upon  a  typical  example  of  a  congenital  change  of  this  nature, 
inferred  that  the  cysts  were  dilated  Malpighian  capsules,  but  it  is  not 
unlikely  that  with  recent  methods  this  excellent  observer  might  have  been 

*  Path.  Trans,  vol.  xxi.  p.  244. 
» Ibid.  vol.  xix.  p.  274. 

^  Bright  on  Abdominal  Tumors  (Sydenham  Society)  p.  208. 

*  Case  reported  by  Dr.  Lever,  Path.  Trans.  1848-49,  p.  74. 


118  CYSTIC    DISEASE    OF   THE   KIDNEY. 

led  to  a  different  result.  The  cystic  transformation  of  foetal  life  is  gene- 
rally associated  with  absence  of  the  ureter  or  pelvis,  or  some  malforma- 
tion which  renders  the  escape  of  urine  impossible.  In  the  case  examined 
by  Gull,  and  reported  by  Lever,  tliere  was  a  total  absence  of  ureters;  and 
in  otlier  instances,  other  parts  of  the  urinary  channels  have  been  oc- 
cluded or  deficient.  In  certain  cases  Virchow  found  closure  of  the 
straight  tubes  a  result,  as  he  supposed,  of  the  impaction  of  uric  acid  and 
iutra-uterine  nephritis.  In  most  cases  there  has  been  absence  or  im- 
perfection of  the  pelvis,  ureters,  or  other  of  the  larger  exists,  which  has 
been  often  associated  with  malformations  in  other  parts  of  the  body. 

The  absence  of  renal  function  in  these  cases  may  cause  the  death  and 
premature  exi)ulsion  of  the  foetus;  the  abdominal  tumor  which  arises 
may  be  such  as  to  be  a  hindrance  to  birth,  which  can  only  be  overcome 
by  operation;  or,  should  tiiis  difficulty  be  overcome  the  child  may  per- 
ish shortly  afterwards  from  respiratory  embarrassment,  due  to  the  en- 
croachment of  the  abdominal  swelling  upon  the  thoracic  cavity. 

Solitary  Eenal  Cysts. 

Otherwise  healthy  kidneys  are  often  found,  especially  in  persons  of 
advancing  years,  to  contain  small  solitary  cysts,  which  project  from  the 
capsule  and  burst  with  miniature  violence  as  this  is  being  removed.  These 
are  apparently  of  the  same  nature  as  the  multiple  cysts  which  have  re- 
ceived attention,  due  to  the  accidental  occlusion  of  a  single  tube.  Such 
cysts  may  occupy  either  the  cortices  or  cones,  may  be  absolutely  single, 
or  be  accompanied  with  one  or  two  others,  as  if  to  declare  their  alliance 
with  the  multiple  cystic  disease,  and  they  may  attain  a  considerable  size, 
so  as  to  come  within  the  category  of  renal  tumors.  They  usually  have  a 
thin  wall,  scarcely  to  be  separated  from  the  renal  tissue,  and  have  been 
found  to  contain  urinous,  albuminous,  gelatinous,  and  bloody  fluid,  uri- 
nary salts  and  cholesterin.  A  cyst  probably  differing  only  in  size  from 
the  small  and  multiple  variety  is  to  be  seen  at  the  College  of  Surgeons. 
It  is  thin-walled  and  membranous,  of  spherical  form,  and  six  inches  in 
diameter.  This  protrudes  from  the  outer  surface  of  a  somewhat  en- 
larged kidney,  Avhicli  is  granular,  and  exhibits  a  few  more  cysts,  appar- 
ently of  the  same  sort,  but  only  a  line  or  two  in  diameter.  This  must 
have  formed  an  abdominal  tumor  of  considerable  prominence. 

Paranephric  Cysts. 

There  are  some  cysts,  not  always  of  the  same  kind,  but  which  may  be 
classed  together  as  neither  developed  in  the  kidney  tissue  nor  dilatations 
of  its  cavity,  though  they  often  open  into  it,  but  as  involving  the  organ 
from  the  outside.  The  terms 2^c(ra}iephric,  or  pararenal,  may  be  applied 
to  these  formations  as  to  solid  tumors  similarly  placed.  Some  of  these 
cysts  are  congenital,  others  of  later  and  perlia])s  doubtful  origin.  The 
occasional  connection  of  these  cavities  with  that  of  the  pelvis  must  make 
them  clinically  indistinguishable  from  hydronephrosis,  however  distinct 
in  their  nature. 

A  preparation  at  St.  George's  Hospital  displays  a  renal  annex  of  this 
kind. 

A  large  cyst  protruded  from  the  back  of  the  pelvis,  which  is  generally  out 
little  dilated,  and  is  scarcely  unnatural  except  that  its  posterior  wall  opens  into 
the  cyst  behind  it.     Tlie  ureter  which  was  unobstructed  opened  into  the  cyst,  so 


CYSTIC    DISEASE    OF    THE    KIDNEY.  119 

that  this  cavity  lay  in  the  course  of  the  urine,  between  the  pelvis  and  its  duct. 
The  cyst  resembled  in  extent,  and  somewhat  in  shape,  a  distended  stomach,  and 
held  above  four  pints  of  clear  albuminous  fluid. 

The  abdominal  tumor  was  first  noticed  when  the  patient,  a  woman  of  the  age 
of  thirty-seven,  was  brought  into  the  hospital  in  consequence  of  having  been 
knocked  down  in  the  street.  She  fell  down,  became  unconscious,  and  died  in  a 
few  liours  from  causes  which  the  post-mortem  imperfectly  explained.  She  had 
emphysema  and  bronchitis. 

Some  aqueous  cysts  present  themselves  in  connection  with  tlie  kidney, 
but  clearly  external  in  origin  as  well  as  jiosition. 

A  remarkable  preparation  of  this  sort  is  to  be  seen  at  St.  George's,  and  is  de- 
scribed by  Mr.  Caesar  Hawkins  in  the  eighteenth  volume  of  the  "  Medico-Chirur- 
gical  Transactions."  It  had  presented  itself  three  months  before  death  as  a  tumor 
in  the  right  side  of  the  abdomen  of  a  boy  six  years  of  age.  The  cyst,  which  held 
five  pints  of  transparent  fluid,  ascertained  by  Dr.  Prout  to  be  free  from  urinary 
constituents,  lay  beliind  the  kidney,  which  was  closely  attached  to  its  wall,  but 
had  no  essential  connection  with  it. 

Tliere  were,  however,  two  small  openings  in  the  pelvis,  apparently  the  result 
of  ulceration,  which  made  communication  between  the  renal  and  the  cystic  cavi- 
ties. The  ureter  had  no  communication  with  the  cavity  of  the  cyst,  but  entered 
tlie  kidney  in  the  usual  manner.  Attached  to  the  cyst  wall  was  a  itidimentary 
tliird  kidney  of  the  size  of  a  walnut.  A  prolongation  of  the  cyst  passed  under 
Pouparfs  ligament,  and  through  tlie  femoral  ring.  Tlie  formation  was  clearly 
of  foetal  origin.  I  have  elsewhere  alluded  to  a  case  (p.  48)  in  which'  the  the  ap- 
pearance in  the  scrotum  of  a  portion  of  a  cystic  growth  of  equivocal  origin  led  to 
a  just  inference  that  it  had  originated  not  within,  but  outside,  the  kidney,  the 
outlying  portion  having  probably  been  brought  down  with  the  descending  testicle, 
the  embryonic  tissues  about  which  organ  in  its  first  situation  being,  as  it  seems, 
rather  apt  to  undergo  morbid  development. 


CHAPTEE    XL 

RENAL   CALCULI   IX    GEXERAL   AND    PARTICULAR,  WITH 

THEIR  CAUSES. 

GeKERAL     CoNSIDERATIOXS     RELATIXa     TO     THEIR     FORMATION     AXD 

Distribution. 

Many  secretions — urine,  bile,  saliva,  and  the  secretions  of  the  pro- 
state gland  and  tonsils — are  apt  to  throw  down  witliin  their  channels  or 
reservoirs  certain  of  their  elements  which  are  superabnndant,  or  which, 
from  other  circnm stances,  are  no  longer  capable  of  solution.  Of  all  se- 
cretions, the  nrinary  is  the  most  apt  to  undertake  this  process.  It  is 
highly  complex  and  highly  variable.  Furnishing,  as  it  does,  the  main 
exit  by  which  the  blood  discharges  its  superfluities  of  almost  every  kind, 
its  several  components  change  in  amount  with  every  change  of  system. 
According  to  the  nature  of  the  superfluities  which  it  thus  receives,  the 
urine  continually  becomes  loaded  beyond  its  capacity  of  continuous  solu- 
tion with  various  materials,  which  are  in  their  Avay  out  precipitated  in 
one  part  or  another  of  the  complicated  urinary  channels.  Besides  the 
numerous  deposits  which  thus  result  from  an  excess  in  the  urine  of  their 
components,  there  are  others  which  owe  their  precipitation,  not  to  any 
superabundance  of  their  material,  but  to  some  change  in  the  urine 
which  renders  it  less  than  naturally  capable  of  holding  it  in  solution. 

The  precipitation  is  most  apt  to  occur  in  the  pelvis  of  the  kidney  and 
in  the  bladder,  in  which  cavities  the  urine  may  remain  for  a  time  in  con- 
siderable bulk  and  in  comparative  quiescence.  Calculi,  especially  if  they 
be  composed  of  uric  acid,  oxalate  of  lime,  or  cystine,  generally  take  their 
first  concrete  form  in  the  pelvis,  though  they  sometimes  escape  notice 
until  they  have  reached  the  bladder,  become  the  centres  of  further  con- 
cretion, and  the  source  of  vesical  symptoms. 

Renal,  though  generally  more  simple  than  vesical,  calculi,  present  a 
considerable  variety  of  composition.  Tlie  following  concretions  have  beea 
found  in  the  human  kidney,  or  presumably  passed  from  it: 

f  Uric  acid. 

I  The  urates  of  soda  and  ammonia. 

I  Oxalate  of  lime. 

Primary  deposits     -[  Sfiato/tae; 

Cystine  or  cystic  oxide. 
Xanthine  or  uric  oxide. 
Indigo  (?) 
i  ]\Iixed  phosphates  (fusible  calculus). 
Secondary  deposits  ^.  Phospliate  of  ammonia  and  magnesia. 
( Carbonate  of  lime. 

Those  classed  as  primary  deposits,  or  at  least  the  first  six  of  them — 


RENAL    CALCULI.  12L 

for  of  xanthine  and  incligo  we  know  but  little — are  thrown  down  in  the 
kidney  independently  of  any  preceding;  local  change.  When  renal  cal- 
culi consist  of  one  ingredient  only,  they  are  always  composed  of  one  of 
these  substances.  When  renal  calculi  consist  of  more  than  one  material, 
one  of  these  substance  invariably  forms  the  nucleus. 

The  three  secondary  deposits  occur  only  in  kidneys  which  have  been 
the  seat  of  previous  disease;  they  are  continually  deposited  upon  stones 
of  some  other  sort,  as  the  result  of  the  pathological  changes  they  have 
set  up.  They  occur  as  layers  upon  the  primary  calculi,  never  as  inde- 
pendent concretions  in  healthy  kidneys. 

In  order  to  give  a  general  idea  of  the  relative  frequency  and  mode 
of  combination  of  the  different  kinds  of  calculous  substances — a  point  of 
great  practical  importance — I  have  compiled  the  following  table,  wiiich 
gives  the  composition  of  ninety-one  analyzed  renal  calculi  belonging  to  the 
thirteen  pathological  museums  of  London.  Considering  from  what  scat- 
tered sources  the  hospitals  of  the  metropolis  attract  ])atients  and  specimens, 
it  may  be  held  that  the  collection  represents  not  merely  the  local  tenden- 
cies of  London,  should  there  be  such  in  relation  to  this  question,  but 
comprises  the  jiroduce  of  a  wide  field  of  disease,  and  jierhaps  portrays  not 
very  unfairly  the  general  constitution  of  English  renal  stones. 

The  table  has  been  compiled  with  much  care,  the  results  of  personal 
inspection  having  been  in  the  case  of  each  of  the  hos])itals  corrobo- 
rated or  coi'rected  by  the  gentleman  in  charge  of  the  museum,' 

It  may  be  assumed  that  tlie  errors  of  the  table  are  only  of  omission. 
There  is  no  I'eason  to  doubt  in  any  instance  the  existence  of  the  calcu- 
lous substances  in  the  position  assigned  to  them.  But,  on  the  other  hand, 
it  is  by  no  means  unlikely  that  many  of  the  concretions  may  have  con- 
tained matter  which  escaped  observation,  so  that  calculi  represented  as 
simple  might,  to  a  more  minute  analysis,  have  declared  themselves  com- 
pound. Hence  it  must  be  taken  that  the  table  rather  under-  than  over- 
states the  complexity  of  renal  stones. 

The  calculi  were  in  most  cases  obtained  from  the  body  after  death, 
though  one  or  two  examples  have  been  included  of  calculi  voided  by  the 
urethra  immediately  after  a  nephralgia  attack. 

The  table  gives  the  composition  of  ninety-one  renal  calculi.  Of  these 
fifty-two  are  simple;  thirty-nine  compound.  Of  the  compound  stones, 
twenty-two  are  composed  of  two  ingredients;  ten  fo  three;  seven  of  four. 

As  regards  the  simple  calculi,  uric  acid  is  their  most  frequent  mate- 
rial, forming  rather  more  than  a  tliird  of  the  number.  Oxalate  of  lime 
comes  next.  Mixed  and  triple  phosphates  occur  not  seldom  in  the  guise 
of  sinii)le  calculi,  though  it  is  probable  that,  in  some  cases  at  least,  a  nu- 
cleus of  a  different  substance  would  have  come  into  view  had  the  section 
fallen  more  happily. 

The  list  does  not  comprise  any  example  of  the  pure  phosphate-of- 
lime  calculus,  the  concretions  of  which  are  described  as  phosphate  of 
lime,  from  the  circumstances  under  which  they  were  found,  almost  cer- 
tainly (see  note  1,  p.   122)  consisting  of  the  mixed  phosphates.     Carbo- 

'  I  have  to  acknowledge  my  obligations  to  Dr.  Green  at  the  Charing  Cross 
Hospital,  Dr.  Moxon  at  Guy's,  Dr.  Kelly  at  King's  College,  Mr.  McCarthy  at  the 
London  Hospital,  Dr,  Cayley  at  the  Middlesex,  Dr.  Gee  at  St.  Bartholomew's,  Dr, 
Payne  at  St.  Mary's,  and  R.  J.  Lee  at  the  Westminster,  all  of  whom  liave  given 
me  assistance  in  this  matter.  To  Mr.  Carter  at  University  College  I  am  indebted 
in  an  especial  manner,  since  he  undertook,  with  a  view  to  this  inquiry,  the  analy- 
sis of  seven  calculi  which  had  not  previously  been  examined. 


122 


RENAL    CALCULI. 


Table  slioioing  the  Xumher  and  Comjjosition  of  the  Renal  Calculi  in  the 

{March, 


Composition  of  Stone. 


C  Uric  acid 

S  c  I  Mixed  iirates 

c  -2  j  Oxalate  of  lime. ..... 

•^  "^  )  Phospliate  of  lime  (?) 

^  %.']  Phosphate  of  ammonia  and  magnesia. 

'tt  S   I  Mixed  phosphates.  . 

c^  g   I  Carbonate  of  lime . . ; 

'-'=       LCystin 


f  ( Uric  acid  +  urates) 

Uric  acid  +  oxalate  of  lime 

( Uric  acid  +  oxalate  of  lime 

Uric  acid  +  mixed  i^hosphates  

(Oxalate  of  lime  +  urates) 

-  Oxalate  of  lime  +  phosphate  of  lime 

(Oxalate  of  lime  +2ihosphate  of  lime) 

Oxalate  of  lime  +  mixed  phosphates 

{Oxalate  of  lime  +  carbonate  of  lime)  

{Pliosphate  of  lime  +  mixed 2ihosphates) 

Mixed  phosphates  +  phosphate  of  ammonia  and  magnesia 


( Uric  acid  +  nrates  +  oxalate  of  lime) 

Urates  +  oxalate  +  uric  acid 

Urates  +  (phosphate  of  lime  +  urates  +  oxalate  of  lime) 

(Oxalate  of  lime  +  urates)  +  phosphates 

{Oxalate  of  lime  +  phosphate  of  lime  +  phosphate  of  ammonia  and 

magnesia) 

(Oxalate  of  lime  -t  jyhosphate  of  lime)  +  carbonate  of  lime 

(Oxalate  of  lime  +  carbonate  of  lime  +  uric  acid)  ....    

[  Phosphate  of  lime  +  carbonate  of  lime  +  urates  


fUric  acid  +  (urate  of  lime  +  urates  -r  phosphates)   

(  Uric  acid  +  urates  +  phosphates  +  oxalate  of  lime) 

Urates  +  oxalate  of  lime  +  (mixed  phosphates  +  carbonate  of  lime) 

Urates  +  uric  acid  +  (oxalate  of  lime  +  phosphate  of  lime) 

( Urates  +  uric  acid  -^  oxalate  of  lime)  +  mixed  phosphates 

Oxalate  of  lime  -i-  (phosphate  of  lime  +  urates  +  phosphate  of  am- 
monia and  magnesia) 

(Phospliate  of  lime  +  phosphate  of  ammonia  and  magnesia  f  car- 
bona'te  of  lime)  -f-  oxalate 


21 
3 

11 
3 

2 

9 
1 

2 

7 
1 
3 
1 
2 

1 
1 

2 

1 


1 

1 
'Jl 


Wliere  not  expressed  to  tlie  contrari%  the  components  of  the  calculus  are  placed  in  their  order 
of  position,  ]irocepdiii{;  from  the  centre  to  the  ciicnniference. 

Uonipoiieuts  which  are  printed  in  italics  and  lirackeied  are  either  not  regularly  superimposed, 
or  are  insufficiently  described  as  to  their  relative  position. 

Calculi  in  both  kidneys,  or  several  calculi  in  one  kidney,  if  of  the  same  kind ,  count  only  as  one. 

'  The  two  specimens  described  as  phosphate  of  lime,  in   Guj^'s  Museum,  were 
taken  from  otherwise  diseased  kidneys,  and  may  be  looked  upon  as  certainly  of 


KENAL    CALCULI. 


123 


Pathological  Museums  of  London,  which  have  heoi  chemically  examined. 
1871.) 


Number  in  each  Museum. 


College  of  Physicians. 

c 
o 

s 
o 

IS 

u 

£ 
o 

0 

Guy's  Hospital. 

King's    College    Hos 
pital. 

5 

te 

0 

K 

B 
0 

•a 

0 

0 

tEl 

ii 

■3 
•a 

g 
0 
0 

ai'a 

■5. 
w 

0 

C 

02 

3 
■5, 
0 

K 

te 

3a 

3 
0 

to 

s 

0 

H 
o5 

m 
it 
<u 

0 
0 

0 

K 

to 

a 

1 

i 

10 
1 
2 

'2 

2 

01 

1 

3 

2 

2 

"2 
11 
IS 

14 

1 
2 

3^ 

2 

i 

i 

1 

1 
35 

"i 
i 

1 

2 

i 
1 

1 

i 

* 
• 

1 

"i 
1 

i 

i 
i 

_ 

1 
i 

■ 

'2 

i 

2 
1 

_ 

1 
'i 

1 

'i 
1 
1 

1 

1 

4 

1 

1 

28 

3 

10 

1 

6 

11 

14 

3 

2 

8 

1 

tlie  mixed  i)liosphates.  That  in  St.  Bartlioloniew's  i.s  described  as  mixed  Avith 
much  animal  matter,  and  similarly  must  probably  be  regarded  as  of  mixed  phos- 
phates. Tliere  is,  therefore,  no  renal  calculus  of  pure  phosphate  of  lime  included 
in  the  table. 

'  There  was  another  calculus  in  the  same  kidney,  which  consisted  externally 
of  the  mixed  phosphates.     It  was  not  examined  internally. 

^  One  of  these  specimens  was  obtained  from  a  man  who  had  previously  got  rid 
of,  by  operation  and  natui'al  expulsion,  both  uric  ai^id  and  oxalate-of-lime  calculi. 

•*  This  calculus  was  dusted  over  with  plates  of  cholesterin. 

*  In  two  of  tliese  specimens  the  urates  only  amounted  to  a  trace. 


124  RENAL    CALCULI. 

Abstract  of  Table  sliowing  frequency  with  ivhich  each  substance  occurred 
in  Simple  and  Compound  Calculi, 

91  calculi:  52  simple:  39  compound. 

Uric  acid  occurred  in,     .         .        .  40  calculi,  21  simple,  19  compound 

Urates, 24        "        3       "  21 

Oxalate  of  lime 36        "      11       "  26         " 

Phospliate  of  lime.           .         .         .  16(?)    "        3(?)  "  13          " 
Phosphate  of  ammonia  and  mag- 
nesia   7        "         2      "  5 

Mixed  phosphates,           .         .         .  20        "         9      ''  11          " 

Carbonate  of  lime,           ...  8        "          1      "  17          " 

C}-stine 2        "         2      "  0          " 

n.ate  of  lime  occurred  in  one  instance — I  believe  a  unique  specimen;  cys- 
tine in  two.     Of  xanthine  there  is  no  example. 

As  to  the  compound  calculi,  it  appears  that  they  have  almost  inva- 
riably sprung  from  a  nucleus  of  oxalate  of  lime,  uric  acid,  or  the  urates. 
Oxalate  of  lime  occurs  most  often  in  this  relationship,  and  indeed  is 
the  most  frequent  constituent  of  compound  calculi,  existing  in  about 
two-thirds  of  the  whole  number.  The  tendency  of  oxalate-of-lime  cal- 
culi to  become  compound  may  be  explained  partly  by  the  fact  that  such 
stones  are,  from  their  roughness  and  hardness,  particularly  apt  to  set  up 
local  inflammation  and  consequent  phosphatic  deposition,  and  partly 
by  the  consideration  that  persons  who  have  deposited  one  lime  salt  are 
constitutionally  liable  to  deposit  another. 

Regarding  the  presence  of  the  pliosphates  in  these  calculi,  it  is  of 
little  practical  importance  to  distinguish  the  calculi-phosphate  from  the 
ammonio-magnesic,  or  the  mixture  of  the  two  from  either  alone.  These 
salts  are  all  the  pj'oduct  of  alkaline  urine,  and  are  apt  to  occur  in  succes- 
sion or  jointly.  They  are  all  incapable  of  being  diminished,  but,  on 
the  otlier  hand,  are  liable  to  be  increased  by  the  use  of  alkaline  solvents. 

Tlic  same  statements  apj^ly  to  carbonate  of  lime,  which  is  often  de- 
posited in  association  with  the  phosphates.  Of  the  compound  calculi, 
twenty-four  out  of  the  thirty-nine,  or  about  three-fifths,  contained  either 
one  of  the  phosphates  or  carbonate  of  lime;  and  thus  had  grown,  as  we 
may  certainly  infer,  in  connection  witli  alkaline  urine;  a  fact,  the  im- 
portance of  which  will  appear  in  relation  to  the  action  of  solvents.  Of 
the  whole  number  of  calculi,  simple  and  compound,  included  in  the 
table  it  is  worth  observing  that  thirty-one  were  wholly  composed  of  uric 
acid  and  urates,  while  there  were  forty  calculi  in  whicii  uric  acid  appeared 
either  alone  or  with  other  matters.  Uric  acid  therefore  was  not  present 
in  half  the  number;  and  did  not  compose  wholly,  or  with  the  sole  assist- 
ance of  the  urates,  above  a  third.  The  proportions  do  not  bear  out  a 
statement  sometimes  made,  that  three-fourths,  or  even  five-sixths,  of  all 
renal  calculi  are  composed  of  uric  acid;  it  is  probable,  however,  that  uric 
acid  would  be  found  in  greater  proportion  in  the  smaller  stones  of  routine 
practice  than  in  these  museum  specimens,  which  especially  represent  ad- 
vanced disease,  and,  of  necessity,  phosphatic  deposits.' 

Of  the  ninety-one  renal  stone,  fifty-eight  contained  oxalate  of  lime, 
one  of  the  phosphates,  or  carbonate  of  lime.  The  carbonate  of  lime  and 
the  phosphates  forming  usually  the  superficial  layer,  would  not  only  have 

'  Dr.  Bence  Jones  stated  tliat  75  per  cent  of  all  renal  calculi  are  uric  acid;  Dr. 
Roberts,  that  five-sixths  are  thus  composed. 


RENAL    CALCULI.  125 

prevented  the  entire  solution  of  the  stone,  but  would  have  prohibited  any 
commencement  of  the  solvent  process. 

Since  these  observations  were  made,  Dr.  Vandyke  Carter  has  brought 
forward  some  important  evidence  with  regard  to  the  components  of  the 
calculi  of  India.' 

"01  s\xtj-two  vesical  calculi,''  says  this  observer,  "the  nucleus  was 
composed  of  urates  mixed 'with  crystals  of  oxalate  thirty-four  times;  of 
oxalate  chiefly  twenty-one  times;  of  uric  acid  chiefly  seven  times."  Thus 
of  sixty-two  calculi  the  nucleus  of  fifty-four  consisted  wholly  or  in  part 
of  this  salt  of  lime.  Speaking  of  its  presence  in  vesical  calculi  generally, 
either  centrally  or  otherwise,  it  was  found  to  be  tlieir  most  frequent  com- 
ponent occurring  in  no  less  than  seventy  per  cent  of  those  examined. 
Urates  which  came  next  in  frequency  were  found  in  sixty-two  per  cent; 
uric  acid  in  thirty-six  per  cent.  These  observations  relate  only  to  India, 
where  possibly  uric  acid  may  be  less  common,  and  oxalate  of  lime  more 
so,  than  in  England;  but  it  is  probable  that  under  all  circumstances  oxa- 
late of  lime,  with  its  remarkable  tendency  to  crystalline  aggregation, 
more  often  lays  the  first  stone  of  calculus,  though  as  a  urinary  deposit 
it  is  far  less  common  than  the  urates  and  uric  acid. 

There  are  several  points  in  relation  to  the  origin  of  urinary  calculi, 
which,  since  they  are  common  to  many  kinds,  may  be  referred  to  before 
entering  upon  the  separate  consideration  of  each.  These  stones  are  often 
highly  complex  in  their  nature,  consisting  of  many  ingredients,  and 
these  arranged  in  an  elaborate  manner.  Dr.  Vandyke  Carter''  has 
shown  that  their  structure  is  largely  crystalline,  and  that  the  crystals 
present  much  variety  of  form  and  arrangement,  sometimes  giving  rise  to 
patterns  which  simulate  agates  or  some  other  production  of  the  mineral 
kingdom.  In  the  next  place,  there  is  a  constant  intermixture,  and  some- 
times the  existence,  as  a  nucleus,  of  animal  matter.  Particles  of  blood- 
clot  have  long  ago  been  referred  to  as  forming  the  centres  of  urinary 
stones,  and  Bilharzia  have  since  been  found  in  the  same  position.  Dr. 
Vandyke  Carter  states  that  in  his  examination  of  the  calculi  of  India,  an 
organic  basis  was  generally  to  be  detected  after  the  removal  by  solvents 
of  the  stony  matter.  This  was  distinctly  to  be  seen,  whether  as  a  basis 
or  a  subordinate  formation  in  calculi  of  uric  acid,  urates,  or  the  oxalate. 
It  is  described  as  a  translucent,  generally  structureless,  substance,  inter- 
fused through  the  stone;  it  is  not  to  be  supposed  that  it  is  other  than  a 
secondary  product.  The  crystallization  occurs  in  an  organic  fluid,  and 
organic  matter  must  needs  be  involved. 

The  varying  consistence  of  the  urine  in  which  the  calculi  are  engen- 
dered, and  the  various  intermixture  with  them,  particularly  with  the 
))hosphatic  kinds,  of  mucus  and  other  morbid  secretions,  have,  as  Dr. 
Ord  has  shown,  a  large  influence  upon  the  mode  and  character  of  the 
crystallization. 

The  influence  of  viscidity  in  the  mothor  liquor  in  the  determination 
of  globular  forms,  as  of  carbonate  of  lime,  is  not  to  be  disputed,  and  it 
must  be  allowed  that  crystals  of  the  oxalate  are  occasionally  to  be  found 
in  a  web  of  mucus  or  fibrin,  like  fish  in  a  net;  but  it  is  not  clear  whether 
the  crystals  have  collected  the  Aveb  or  the  web  the  crystals;  and  perhaps 
we  should  hardly  be  justified  in  assigning  to  tenacious  admixtures  so 
large  a  part  in  the  begetting  of  calculi  as  Dr.  Ord  is  disposed  to  do.' 

'  On  the  Structure  and  Formation  of  Urinary  Calculi.    London,  1873. 

*  Loc.  cit. 

^  I  am  enabled,  by  Dr.  Ord's  courtesy,  to  subjoin  an  abstract  of  his  views  in 


126  KENAL  CALCULI. 

I  think  it  is  to  be  asserted  with  general  truth  that,  putting  aside  the 
phosphates  and  carbonates,  calculi  are  formed  more  often  in  obedience  to 
systemic  states  and  consequent  variations  in  the  normal  constituents  of 
the  urine  than  from  local  disease  or  "  colloid"  admixture.  Stones  are 
not  especially  common  with  albuminuria  and  diabetes  where  colloids  and 
viscidity  abound.  On  the  other  hand,  we  have  sufficient  evidence  that 
they  abound  much  in  proportion  to  the  abumlance  of  their  material  in 
the  urine  and  the  degree  of  concentration  of  that  secretion.  Thus  calculi 
are  common  as  in  Xor/olk,  where  the  drinking  water  is  hard  and  the  ex- 
cretion of  lime  necessarily  superabundant;  they  occur  especially  in  per- 
sons whose  habits  or  predispositions  tend  to  the  making  of  uric  acid; 
and  it  is  a  matter  of  unwritten  as  well  as  of  recorded  experience  that 
calculous  disorders  are  frequent  in  India,  where  the  renal  secretion  is 
drained  of  water  by  that  of  the  skin. 

The  geographical  distribution  of  urinary  calculus  throws  great  light 
upon  its  causation.  Tiie  prevalence  of  this  disorder  in  the  eastern 
countries,  especially  in  Norfolk,  has  long  been  a  matter  of  notoriety.  It 
has  recently  been  numerically  displayed  by  Mr.  Cadge,  of  Norwich,  to 
whose  valuable  yjaper  I  must  refer  for  particulars.  He  has  deduced  from 
the  reports  of  the  Kegistrar-General  that  deaths  from  stone  are  more  fre- 
quent in  proportion  to  the  population  in  Scotland  than  in  England  and 
Wales,  and  in  England  and  AVales  than  in  Ireland.  In  England  the  greatest 
pro2:)ortionate  mortality  from  this  cause  is  in  the  eastern  district,  the 
smallest  in  the  districts  described  respectively  as  the  north-western  and 
south-western.  Arranging  the  counties  of  England  according  to  the  mor- 
tality from  this  cause,  Norfolk,  Huntingdon,  Kent,  and  Sussex  head  the 
list,  Cumberland,  Cornwall,  and  Cheshire  conclude  it.  This  mortality  in 
Norwalk  is  al)out  ten  times  that  in  Cheshire;  in  Norfolk,  1  in  42,744:  of 
the  population;  in  Cheshire,  1  in  4'25,520.'  From  the  experience  of 
hospitals  all  over  Great  Britain  Mr.  Cadge  has  drawn  a  similar  conclu- 
sion. In  the  Norfolk  and  Norwich  Hospital  the  stone  cases  bear  to  the 
total  number  of  in-patients  in  one  year  a  proportion  of  1  to  55;  in  the 
Devon  and  Exeter  Hospital  a  proportion  of  1  to  1,298.  It  is  possible 
that  cases  of  one  sort  may  be  attracted  to  a  local  hospital  by  its  reputa- 
tion in  connection  Avith  their  treatment;  but  this  reputation  may  have 
been  due  to  the  practice  afforded  by  the  prevalence  of  such  cases  in  the 
neighborhood,  and  be  only  another  testimony  to  its  morbid  proclivities; 
while  it  may  be  further  said  that  jDatients  of  the  hospital  class  are  not 

his  own  words: — 1.  lu  experiments  I  have  never  found  oxalates,  or  uric  acid,  or 
urates,  form  calculous  masses  unless  in  tlie  presence  of  colloids.  Uric  acid,  in- 
deed, sometimes  forms  layers  of  matted  crystals  on  the  sides  of  vessels.  2.  In 
the  presence  of  colloids  either  cohesion  or  metamorphosis  to  spherical  form  always 
occurs;  not  always  both.  3.  Hundreds  of  people  pass  uric  acid  and  oxalate  in 
abundance  witliout  getting  calculus.  4.  The  same  may  be  said  of  people  having 
albuminuria  ami  inflammation  of  the  urinary  passages.  5.  I  have  never  exam- 
ined any  calculus  whicli,  in  addition  to  its  crystalline  substance,  had  not  also  a 
colloid  matrix.  6.  I  believe  that  it  is  most  probable  that  no  calculus  is  formed  of 
oxalates,  urates,  and  uric  acid,  or  phosphates,  without  the  intervention  of  a  col- 
loid. This  may  be  albumin  in  solution,  exudation  in  renal  tubes,  mucus  or  exu- 
dations in  renal  passages,  ureters,  or  bladder.  Tlie  most  active  element  in  form- 
ing calculi  I  believe  to  be  the  exudative  matter  of  the  tubes  and  mucus  from  the 
tracts.  With  albumin,  spherical  forms  are  produced,  but  there  is  less  tendency 
to  aggregation.  In  this  I  believe  the  viscidity  of  the  mucus  acts  by  holding  the 
cr3-stals  once  formed  in  such  a  position  as  to  invite  accretion. 

'  '•  Address  in  Surgery,"  by  \V.  Cadge,  Brit.  Med.  Journ.  Aug.  15th,  1874,  p. 
207. 


RENAL    CALCULI.  127 

prone  to  select  distant  institutions  when  nearer  are  available.  The  prac- 
tical conclusion  from  Mr.  Cadge's  extensive  inquiry  is  a  confirmation  of 
tiie  old  belief  that  stone  prevails  where  the  water  is  hard,  or  in  other 
words  contains  a  superabundance  of  lime.  That  this  association  exists  is 
proved  abundantly.  In  Norfolk,  Huntingdonshire,  Kent,  and  Sussex  the 
water  is  almost  invariably  hard;  in  the  western  counties  it  is  generally 
soft.  Stone  ap]iears  to  flourish  upon  chalk  and  limestone,  to  be  but 
sparsely  produced  on  sandstone  and  granite. 

The  prevalcPiCe  of  stone  in  Norfolk  and  the  eastern  counties  has  been 
otherwise  attributed  to  the  coldness  of  the  climate,  the  Teutonic  origin 
of  the  inhabitants,  and  the  use  of  Norfolk  dumplings.  Cold  docs  not 
appear  to  be  productive  of  calculus,  but  rather  the  reverse.  Mr.  Cadge 
informs  us  that  a  smaller  proportion  of  stone  cases  comes  from  the  coast 
of  Norfolk,  where  the  cold  is  greatest,  than  from  the  inland  villages. 
Parts  of  the  eastern  coast,  such  as  Durham,  the  East  Eiding  of  York- 
shire, and  Aberdeen,  which  are  probably  colder  than  Norfolk,  present 
the  disorder  with  less  frequency.  At  the  Norfolk  and  Norwich  Hospital 
1  case  in  55  is  of  stone;  at  the  Infirmary  of  Aberdeen,  1  case  in  184-.  Be- 
yond these  facts  Mr.  Cadge  has  pointed  out,  and  our  knowledge  derived 
from  other  sources  confirms  this  statement,  that  urinary  stone  ia  rare  in 
Sweden,  Norway,  and  some  other  cold  countries,  common  in  India  and 
some  parts  of  China.  From  cases  I  have  seen  I  should  conclude  that 
stone  is  common  in  the  West  Indies  as  well  as  in  the  East,  and  it  must  be 
accepted  as  a  general  truth  that  it  belongs  rather  to  the  warmer  tlian  the 
colder  zones.  It  could  not  indeed  well  be  otlierwise;  the  concentration 
of  the  urine  must  needs  assist  its  crystallization. 

Race  probably  occupies  only  a  secondary  place  in  giving  rise  to  calcu- 
lous disorders.  In  India  both  Europeans  and  natives  suffer;  and  if  in 
Great  Britain  Teutons  are  more  often  affected  than  Celts,  it  is  possible 
that  other  differences  besides  those  of  race  intervene.  The  east  of  Eng- 
land, which  is  most  strongly  Saxon,  is  especially  the  district  of  cereals 
and  beer;  the  beer  district  is  generally  more  jirolific  in  stone  than  where 
the  local  beverage  is  cider  or  whiskey.  The  question  of  diet  in  relation 
to  uric  acid  will  be  further  considered,  but  I  may  refer  in  passing  to  the 
discredit  which  since  Front's  time  has  attached  to  Norfolk  dumplings  as 
a  cause  of  stone.  The  large  local  experience  of  Mr.  Cadge  is  against  the 
view  that  these  dumplings,  wliich  consist  of  flour,  water,  and  yeast,  are 
indigestible  or  unwholesome,  and  we  have  evidence  that  at  least  other 
causes  overrule  this  one;  stone  is  common  in  Kent  and  Sussex,  where  the 
water  is  hard,  but  the  dumpling  unknown. 

The  comparative  infrequency  of  stone  in  Ireland  is  of  interest,  more 
especially  as  the  water  in  many  parts  of  this  country  is  recorded  as  hard. 
The  use  of  whiskey  instead  of  beer  may  help  to  explain  the  absence  at 
least  of  lithatic  deposits,  while  some  of  tiie  immunity  may,  perhaps,  be 
attributed  to  the  potato,  notwithstanding  the  views  Avliich  have  been  pro- 
pounded, on  somewhat  theoretical  grounds,  to  the  effect  that  such  veget- 
able food  jiromotes,  instead  of  preventing,  calculous  deposition.  The  rarity 
of  stone  in  Ireland  may  indeed  be  taken  as  an  argument  in  favor  of 
this  article  of  diet,  rich  as  it  is  in  alkali,  and  poor  in  nitrogen,  in  many 
cases  in  which  it  has  been  the  custom  to  prohibit  it. 

Another  dietetic  point  turns  upon  the  general  infrequency  of  stone 
among  the  children  of  the  rich,  its  commonness  among  those  of  the  poor. 
Operating  surgeons  concur  in  bearing  witness  to  this  disparity, 
which   has  been  made    prominent  by   my   colleague   at  the    Hospital 


128  KENAL   CALCULI. 

for  Sick  Children,  Mr.  T.  Smith.'  He  assigns  the  frequency 
with  which  the  children  of  the  poor  suffer  to  arrested  cutaneous  action 
from  dirt,  and  to  unsuitable  food.  Mr.  Cadge,  probably  Avith  more  ex- 
actness, attributes  it  to  the  absence  of  milk  from  their  dietary.  It  is  ob- 
vious that  where  milk  is  largely  rejilaced  by  bread  or  other  solid  food, 
the  urine  may  fail  to  be  supplied  with  "vvater  in  proportion  to  its  solid 
constituents. 

Putting  aside  hereditary  and  othercausesproper  to  the  individual,  the 
overruling  influence  which  ai)pears  most  strongly  marked  in  the  causation 
of  stone  is  calcareous  impregnation  of  the  water.  It  Avould  be  hanl  to  ex- 
plain this  but  for  such  evidence  as  has  been  already  adduced  with  regard  to 
the  frequency  of  oxalate  of  lime  as  the  nucleus  of  stone,  although  it  may 
be  that  the  later  deposit  is  of  a  different  kind.  Mr.  Cadge  represents 
the  stones  of  Norfolk  as  almost  always  consisting  of  the  salts  of  uric  acid, 
and  deals  with  their  production  as  a  simple  question  of  lithuria.  But  it 
is  not  easy  to  show  how  hard  water  should  determine  this  deposit.  If 
they  are  especially  diuretic,  as  they  are  said  to  be,  they  should,  beyond 
other  waters,  prevent  the  deposition  at  least  of  the  salts  of  uric  acid.  If 
the  stones  thus  begotten  of  water  are  begun  with  the  oxalate,  their 
origin  ceases  to  be  a  mystery.  And  Norfolk  stones  must  be  very  differ- 
ent from  stones  elsewhere,  if  this  is  not  more  often  the  case  than  super- 
ficially appears.  I  have  often  administered  lime  experimentally,  as  lime 
water,  the  saccharated  solution  of  lime,  chalk  mixture,  and  a  solution  of 
the  acetate;  urinary  deposits  result  abundantly,  not  as  uric  acid  or 
urates,  but  as  oxalate  and  phosphate  of  lime.  Crystals  of  the  oxalate 
constantly  appear  from  such  medicaments,  often  of  striking  size  and 
abundance.  Whether  oxalic  acid  is  a  normal  constituent  of  urine  I  will 
not  discuss,  but  it  is  at  least  clear  that  the  oxalate  of  lime  appears  in  a 
large  majority  of  persons  after  the  ingestion  of  the  earth.  This  fact  can- 
not but  throw  light  upon  the  connection  of  calculi  and  hard  water. 

Calculi  being  different  from  each  other  in  physical  and  chemical 
properties,  arising  from  widely  different  causes,  and  requiring  diverse 
and  even  opposite  treatment,  each  must  receive  individual  consideration. 

Umc  Acid  akd  the  Ueic  Acid  Diathesis. 

Uric  acid  is  tlie  most  common  constituent  of  renal  calculi.  The  esti- 
mates of  Bence  Jones  and  Roberts  have  been  stated. 

Sir  H.  Thompson,  speaking  not  especially  of  renal  calculi  but  of  cal- 
culi of  constitutional  as  distinguished  from  local  origin,  says  "  nineteen 
out  of  twenty  of  such  stones  have  uric  acid  for  their  basis,  the  remaining 
one  in  twenty  being  oxalate  of  lime."^  But  I  cannot  doubt,  from  the 
evidence  already  brought  forward,  that  the  frequency  of  uric  acid  in  re- 
nal concretions  is  less  than  these  observers  represent.  From  my  facts 
it  would  ai)pear  that  of  simple  calculi  from  the  kidney,  about  one-half 
are  composed  of  uric  acid  or  urates;  while  of  compound  calculi  more 
than  half  contain  neither  of  tliese  substances.  These  facts  are  of  import- 
ance as  bearing  upon  the  medical  treatment  of  these  deposits. 

Uric  acid  stones  generally  have  a  yellowish,  yellowish-red,  or  gravel 
color.     They  are  harder  and  less  brittle  than  the  mixed  or  triple  phos- 

1  Brit.  Med.  Journ.  18G9  vol.  1,  p.  443. 

'  "  Clinical  Lectures  ou  the  Early  History  of  Calculous  Disease,"  Lancet,  Jan. 
13th, 1872. 


RENAL    CALCULI. 


129 


phates,  but  not  nearly  so  hard  as  oxalate  of  lime.  They  are  usually 
smooth  externally,  arranged  in  concentric  layers  by  a  process  of  even 
stratification;  contrasted  in  this  respect  with  oxalate  of  lime  calculi, 
which  are  spiked,  as  if  dis- 
posed not  upon  the  circum- 
ference, but  the  radii  of  a 
circle. 

Uric  acid  deposits  occur 
in  the  pelvis  of  the  kidney 
in  sizes  which  vary  from  the 
minutestgrains  to  the  weight 
of  nearly  half  a  pound.  The 
accompanying  woodcut  (op- 
posite) represents  a  renal  cal- 
culus at  the  College  of  Sur- 
geons, whicli  consists  of  uric 
acid  deposited  upon  a  nuc- 
leus of  urate  of  ammonia, 
and  weighed  7-^  ounces.  This 
a])pears  to  be  the  maximum. 
Uric  acid  calculi  of  large 
size  are  not  so  frequent  in 
the  kidney  axs  are  large 
phosphatic  stones.  Uric  acid 
more  often  forms  concre- 
tions of  comparatively  mod- 
crate  size,  such  as  are  re- 
presented on  this  and  the 
next  page.  ,   ,  . ,  i  i 

They  are  often  symmetrically  disposed  in  both  kidneys,  dangerously 
obstructing  the  escape  of  urine.     They  frequently  have  a  shape  sugges- 


Renal  calculus  which  weighed  seven  and  a  half  ounces. 
Nucleus  urate  of  ammonia;  remainder  uric  acid,  nearly- 
pure;  oxalate  and  phosijliate  of  lime  on  the  exterior 
(From  illustrated  catalogue,  College  of  Surgeons.) 


Several  small  uric  acid  calculi  from  the 
kidney.  (From  specimens  at  the  College  or 
Surgeons.) 


Uric  acid  calculus  from  the  kid- 
ney. The  shape  is  characteristic. 
( From  a  specimen  at  the  College  of 
Surgeons.) 


tive  of  a  shark's  tooth  or  antique  arrow-head  (sec  also  woodcut  above), 
the  point  being  moulded  in  the  infundibulum,  the  widened  base  lying 


130  RENAL    CALCULI. 

in  the  pelvis,  their  soft  structure  being  worn  by  friction  so  as   to  form, 
plugs  wliich  fit  with  fatal  accuracy. 

A  common  form  of  the  uric  acid  concretion  is  that  described  by  Dr. 
Prout  as  pisiform.*  Numerous  and  minute  concretions,  which  have 
been  likened  to  hemp-seed  or  peas,  often  collect  in  the  pelvis,  and  are 
discharged  with  the  urine,  sometimes  in  great  numbers.  A  gentleman 
under  the  care  of  Mr.  Nunn,  during  the  space  of  two  months  passed  witli 
the  urine  above  SOU  such  calculi,  which  evidently  had  but  recently  left 
the  kidney. 

Uric  acid  calculi  appear  generally  to  originate  in  the  kidney,  often 
while  small  traversing  the  ureter,  painlessly  or  otherwise,  to  become  in 
the  bladder  the  centres  of  concretion,  or  thence  to  be  happily  expelled. 
Under  less  fortunate  circumstances  the  calculi  remain  in  the  kidney,  and 
there  grow  until  they  are  too  large  to  make  their  escape.  Whatever  be 
their  destination,  the  kidney  appears  to  be  their  usual  birthplace  ;  the 
pelvis,  except  in  infancy,  more  often  than  the  tubes.  It  is  known  that 
uric  acid  and  urates  are  apt  to  concrete  in  the  straight  tubes  during  the  first 

ten  days  of  extra-uterine  life,  during  which 
o       ®      f^    <^     ®  <^    period  the  flow  of  urine  is  often  scanty  and 

€^      i(*%i     /^  r\    ii'i"6gwl'ii"'^      1'Jie  crystalline  and  amorphous 

<s     "        ««3     \!^    <1?  (^    masses  thus  produced  may  reach  the  pelvis  in 

Q    <S      /^  fh         '^  concrete  form,  and  tiiere  lurk  in  quiet  to 

^     ^         ^    become  the  seats  of  further  deposition. 
Pisiform    uric    acid   calculi.  The  tubal  Origin  of  uric  acid  calculi  ap- 

passed    by    the     urethra.       (St.  i  F     •,  ■       •    £ 

George's  Hospital.)  jicars,   liowever,   to   be  rare  save  in  miancy. 

Crystals  of  uric  acid  are  seldom  found  in  the 
tubes  after  the  secretion  of  urine  has  been  fairly  established. 

In  its  rapid  movement  and  small  volume,  the  urine  in  the  tubes  is 
not  advantageously  circumstanceil  for  crystallization.  Under  ordinary 
circumstances  it  reaches  the  pelvis  loaded  with  all  its  redundancies. 
During  sleep,  when  the  stream  in  the  ureters  is  not  assisted  by  gravity,. 
and  to  a  less  extent  in  sedentary  postures,  whereby  those  exits  are  com- 
pressed by  unshifted  and  constrained  abdominal  viscera,  the  urine  is  apt 
to  collect,  remain  quiescent  and  deposit.  The  process  is  analogous  to 
what  takes  place  on  a  larger  scale  when  torrents  tlirow  down  mud  on  en- 
tering a  lake.  According  to  Prout  the  uric  acid  is  first  })reci})itated  as  a. 
gelatinous  or  amorphous  hydrate,  which  afterwards  gathers  into  crystals. 
This  process  may  be  accompanied  or  followed  by  a  dull  pain  or  sense  of 
weight  in  the  lumbar  region,  which  may  shortly  pass  away  or  may  give 
place  to  more  marked  signs  of  renal  concretion.  What  is  known  as  to 
the  chemistry  of  uric  acid  in  the  body  may  be  shortly  stated,  and  is 
enough  to  be  of  some  value,  thougli  much  still  remains  to  be  learned. 
Uric  acid  as  an  excrementitious  substance  of  the  nitrogenous  class  sup- 
plies a  form  of  exit  for  a  certain  proportion  of  the  nitrogenous  waste.  It 
is  derived  in  part  from  food,  and  in  part  from  tissue  ;  the  proportion 
which  each  supplies  probably  admitting  of  much  variation.  Food  plays 
an  important  part  in  the  process.  With  healthy  organs  and  sound  diges- 
tion, the  more  nitrogenous  tlie  diet  the  more  uric  acid  is  discharged. 
The  following  table  given  by  Dr.  Harley^  illustrates  this  fact,  and  many 
more  statements  of  the  same  kind  might  be  adduced.     With  wholly 

'  Path.  Trans,  vol.  xvi.  p.  181. 

»  See  p.  134. 

'  Tlie  Urine  and  its  Derangements,  p.  65  (Dr.  Harley). 


RENAL    CALCULI. 


131 


nitrogenous  food  uric  acid  is  at  its  maximum,  with  non-nitrogenous  food 
at  its  minimum. 


Quantity  of  uric  acid  passed  during  twenty-four  hours  hy  healthy  adults. 


Animal 

Mixed 

Vegetable 

Non-nitros«iious 


Lehmann 


1.478 
1.183 
1.031 
0.735 


Harley 


Grammes 

1.250 
0.755 
0.500 
0.340 


When  uric  acid  out  of  the  body  is  subjected  to  an  oxidizing  agent 
in  the  presence  of  water  it  is  converted  into  urea,  and  it  has  been  inferred 
that  a  similar  action  is  continually  taking  place  in  the  body,  that  uric 
acid  in  fact  is  only  an  intermediate  step  between  albumin  and  urea. 
Whether  the  relation  between  these  excrementitious  substances  is  thus 
simple  is  a  matter  as  yet  sub  judice.  Urea  is  believed  to  be  largely 
formed  in  the  liver.  It  is  found  in  the  blood  which  leaves  this  organ  in 
much  larger  proportion  than  in  the  blood  which  enters  it.  In  congestive 
and  other  morbid  conditions  of  the  liver  uric  acid,  with  purpurates,  is 
found  in  excess  in  the  urine,  and  it  may  easily  be  supposed  that  in  the 
embarrassment  which  such  disease  implies  the  process  of  transformation 
may  be  arrested,  so  that  uric  acid  is  discharged  in  the  place  of  the  more 
elaborated  product.  There  is  another  fact,  however,  which,  first  noticed 
by  Dr.  Parkes  '  and  since  observed  by  others,  is  less  easily  explicable  on 
the  theory  that  uric  acid  and  urea  are  only  steps  in  the  same  process.  In 
leucocythaemic  enlargement  of  the  spleen  the  uric  acid  of  the  urine  is 
greatly  increased,  whereas  this  organ  is  not  known  to  have  any  special 
duty  with  regard  to  the  making  of  urea  ;  from  this  it  would  seem  that 
uric  acid  and  urea  take  their  origin  in  different  organs  and  are  indepen- 
dent of  each  other.  Leaving  the  relation  between  urea  and  uric  acid  as 
undetermined,  it  is  enough  for  the  present  purpose  to  regard  uric  acid  as 
the  less  oxidized  i)roduct  of  nitrogenous  waste.  For  the  diminution  of 
uric  acid,  therefore,  chemistry  would  indicate  the  introduction  of  more 
o.xygen  and  less  nitrogen,  more  air  and  less  meat,  practic.il  rules  in  the 
promulgating  of  which  modern  science  has  been  anticipated  by  ancient 
experience. 

Uric  acid  may  be  in  excess  without  being  deposited,  or  it  may  be  de- 
posited when  not  in  excess.  Its  deposition  depends  partly  upon  the 
acidity  of  the  urine,  and  partly  upon  its  dilution.  Alkaline  urine  holds 
it  in  solution.  The  presence  of  a  free  acid  by  which  the  urates  are  de- 
composed, determines  its  precipitation  the  more  readily  the  greater 
its  quantity  and  the  more  concentrated  the  urine.  Another  circumstance 
is  accessory,  the  contact  of  an  inanimate  surface,  which  unprotected  by 
alkaline  secretion  invites  crystallization. 

So  far   no  doubt  presents  itself,  but  the  whole  story  is  not  told. 


'Parkes,   "Lectures  on  the  diminution  of  nitrogen  from  the  human  body," 
Lancet,  April  8th,  1871,  p.  469. 


132  KKNAL    CALCULI. 

Clinical  observation  makes  it  sufficiently  evident  that  the  whole  mystery 
of  uric  acid  is  not  yet  revealed.  Overmuch  nitrogenous  food,  too  little  air 
and  exercise,  whatever  causes  hepatic  congestion,  whether  by  way  of  diet, 
mechanical  obstruction,  or  ague,  may  be  within  our  understanding  as 
causes  of  uric  acid  excess.  Gout  is  likewise  associated  with  it,  though  the 
mode  of  the  association  is  less  clear  than  its  existence. 

I  have  known  uric  acid  gravel  to  be  passed  largely  and  regularly  bv 
pale,  thin,  and  impoverished  old  women,  whose  diet  has  assuredly  com- 
prised no  excess  of  flesh  or  luxurious  food.  With  these  the  deposit  oc- 
curs in  connection  with  dyspepsia  associated  with  a  coarse  and  poor  diet, 
or  with  organic  changes  as  yet  imperfectly  understood. 

Vegetable  food  since  Prout  and  Bence  Jones  has  been  supposed  to  be 
Ji  frequent  source  of  ''acidity."  Prout  insists  on  the  malassimilation  of 
dumplings  and  such  admixtures  of  flour  and  fat,  and  their  effect  in  pro- 
ducing uric  deposits,  Avhile  Bence  Jones  dwells  upon  tlie  amount  and 
variety  of  acid  theoretically  liable  to  be  produced  in  the  course  of  the  con- 
version of  sugar  and  starch  into  carbonic  acid  and  water.  But  we  do  not 
know  how  far  this  acid  transmutation  actually  occurs  in  the  body,  though 
possible  out  of  it. 

We  know  as  a  matter  of  observation  that  under  animal  diet  the  urine 
becomes  more  acid,  under  vegetable  diet  less  acid  or  ali^aline.  With  re- 
gard to  uric  acid  in  particular,  we  have  the  ascertained  increased  excretion 
of  this  acid  upon  animal  diet,  and  its  diminution  upon  vegetable,  and 
to  the  same  purpose  the  infrequency  of  stone  upon  the  potato  diet  of 
Ireland. 

But  whatever  be  the  relation  of  vegetable  food  to  uric  acid,  it  is  at 
least  clear  that  an  excess  of  this  substance  may  occur  under  two  distinct 
and  even  opposite  conditions,  the  one  caused  by  overmuch  food  in  relation 
to  exercise,  the  other  occurring  without  any  such  excess,  to  be  described 
somewhat  vaguely  as  the  product  of  malassimilation,  or  perhaps  more 
correctly  as  the  result  of  organic  conditions  at  present  unknown,  or 
known  but  imperfectly.  The  influence  of  hepatic  and  splenic  changes 
in  the  production  of  uric  acid  has  already  been  adverted  to. 

Deposition  of  uric  acid  is  more  common  towards  the  ends  than  in  the 
middle  of  life — more  common  before  ten  and  after  forty  than  in  the  in- 
tervening ])eriod.  In  infancy  and  childhood  this  tendency  sometimes  is, 
as  Dr.  Prout  has  observed,  obviously  hereditary,  derived  from  gouty  or 
dyspeptic  parents.  Among  the  causes  of  this  deposition  in  early  life 
ne{)hritis,  whether  from  cold  or  scarlatina,  deserves  a  prominent  place. 
During  convalescence  from  this  disease  it  is  not  uncommon  to  find  a  re- 
markable abundance  of  uric  acid  crystals  in  the  urine.  As  the  renal 
channels  reopen  after  their  tem})orary  closure,  the  accumulated  excre- 
mentitious  matters  hurry  out  in  superabundance,  more  uric  acid  escapes 
from  the  kidney  than  can  be  retained  in  solution,  and  crystals  are 
passed,  often  in  great  abundance,  with  the  urine.  It  may  happen  that 
some  remain  behind,  to  become  tlie  centres  of  concretion.  I  have  known 
cases  in  which  the  symi)toms  of  renal  calculus  have  dated  from,  and 
probably  thus  originated  in,  an  attack  of  scarlatinal  nephritis. 

Among  the  pathological  associates  of  uric  acid  diabetes  must  be  men- 
tioned ;  the  deposit  is  often  noticed  in  the  earlier  stages  of  the  disease, 
while  as  yet  the  urine  is  not  veiy  copious;  the  concurrence  may  possibly 
be  attributed  not  so  much  to  greater  or  less  oxidation — a  theoretical 
cause  to  which  both  sugar  and  excess  of  uric  acid  in  the  urine  have  been 


RENAL    CALCULI.  133 

attributed — but  more  probably  to  the  definite  congestion  of  the  liver, 
which  is  iissociuted,  as  I  have  elsewhere  shown,  with  diabetes. 

During  the  vigor  of  early  middle  life  uric  acid  deposits  are  compara- 
tively rare.  They  reappear  when  tlie  habits  of  life  begin  to  produce  their 
results  and  the  changes  of  age  to  commence.  Intimately  connected  as 
uric  acid  is  with  gout,  it  may  be  said  that  after  middle  life  the  causes  of 
gout  are  the  causes  of  the  uric  acid  diathesis.  Both  are  engendered  by 
bodily  inactivity,  and  occur  in  those  who  have  lived  not  wisely  but  too 
well." 

As  to  the  treatment  of  tlie  uric  acid  diathesis,  or,  in  other  words,  the 
prevention  of  uric  acid  calculi,  we  may  be  wise  in  our  present  state  of 
knowledge  to  be  mainly  guided  by  the  results  of  clinical  observation.. 
Experience  is  not  in  favor  of  a  general  recourse  to  an  exclusively  or 
mainly  animal  diet,  though  according  to  Bence  Jones,  the  fare  in  extreme 
cases  of  the  uric  acid  diathesis  should  assimilate  t(^  that  of  diabetes — 
little  more  than  lean  meat  and  brandy  and  water.  It  appears  to  be  gen- 
erally wise  to  cut  off  saccharine  and  oleaginous  matters  and  indigestible 
forms  of  pastry,  though  I  believe  harm  has  been  done  in  this  condition 
by  the  too  general  avoidance  of  vegetable  food.  Malt  liquor  must  be  en- 
tirely interdicted.  It  has  been  observed  that  as  productive  of  uric  acid 
the  presence  of  acetic  acid  in  any  liquor  is  more  injurious  than  that  of 
malic,  tartaric,  or  citric  acid  ;  hence  beer  does  more  harm  in  this  respect 
than  wine  or  cider.  All  rich  and  imperfectly  fermented  wines,  port,  ricli 
sherry,  burgundy,  and  champagne  must  be  avoided,  and  the  patient  re- 
stricted to  claret  or  weak  spirit  and  water.  Excess  of  uric  acid  is  often 
cured  by  poverty,  with  its  attendant  advantages  of  frugal  fare,  abstinence, 
and  exercise. 

Spare  diet  and  spring  water  clear 
Physicians  hold  are  good, 

especially  for  those  who  make  uric  acid  superabundantly.  Of  this  pre- 
scription the  water  plays  no  unimportant  part.  It  is  impossible  to  ex- 
aggerate the  use  of  diluents,  of  which  none  can  be  better  than  pure 
water,  in  the  treatment  of  urinary  concretions,  particularly  when  they 
are  of  this  kind.  Water  is  a  universal  solvent:  it  furnishes  the  natural 
vehicle  for  the  removal  of  all  the  urinary  excreta:  it  is  a  diuretic  of  rare 
virtue,  for  it  is  free  from  irritating  properties,  while  it  has  the  power, 
rarely  possessed  by  medicines  of  the  diuretic  class,  of  increasing  the  solids 
of  the  urine.  And  beside  its  effect  in  purifying  the  blood  by  increased 
urinary  elimination,  it  will  by  its  solvent  action  prevent  precipitation  so 
effectually  that  it  may  be  generally  stated  that  the  tendency  to  the  crystal- 
lization of  uric  acid  will  diminish  precisely  in  the  same  proportion  as  the 
urine  is  diluted. 

Enough  has  been  said  of  air  and  exercise  to  show  their  paramount, 
almost  specific,  importance. 

However  the  liver  may  be  concerned  in  the  production  of  uric  acid 
or  in  the  action  of  mercury,  there,  is  no  doubt  that  occasional  doses  of 
calomel  and  of  some  saline  aperient,  as  sulphate  of  magnesia  or  some 
purging  mineral  water,  as  Pullna  or  Friedrichshall,  are  often  beneficial. 

Alkaline  remedies,  the  bicarbonate,  or,  what  comes  to  the  same  thing, 
the  citrate  of  potash,  or,  less  effectively,  lithia  in  similar  combination, 
may  be  trusted  as  a  means  of  preventing  the  precipitation  of  uric  acid, 
though  they  do  not  lessen  its  production. 

For  habitual  use  the  effervescing  potash  water,  containing  from  ten 


134  KENAL    CALCULI, 

to  twenty  grains  of  the  bicarbonate  to  the  bottle,  is  convenient  and  agree- 
able. Vichy  water  answers  much  the  same  purpose:  it  often  proves  of 
great  service  in  preventing  the  deposition  of  the  uric  acid;  as  containing 
soda,  however,  it  is  probably  less  efficacious,  and  is  in  some  respects  more 
objectionable  than  solutions  of  potash.  The  water  of  Contrexeville'  has 
been  vaunted  in  disorders  of  the  uric  acid  kind;  it  seems  to  have  a  marked 
diuretic  action,  and  it  is  supposed  thus  to  expel  gravel  and  small  calculi 
Avhich  otherwise  might  have  grown  in  peace;  it,  however,  contains  a  large 
quantity  of  lime,  which  must  be  a  source  of  danger  where  the  formation 
of  the  oxalate  or  i)hosphate  is  to  be  apprehended. 

In  connection  with  tiie  etfect  attributed  to  these  waters,  abounding 
lis  they  do  with  lime,^  Prout  noticed  that  hard  waters,  thougli  generally 
to  be  avoided  in  calculous  disease,  sometimes  brought  away  large  quanti- 
ties of  gravel  by  their  diuretic  action.  Similar  results  occasionally  follow 
terebinthinate  remedies.^  Dr.  Henry  related  the  case  of  a  middle-aged 
lady  who,  when  led  by  customary  symptoms  to  expect  a  fit  of  gravel,  was 
in  the  habit  of  taking  a  mixture  chiefly  consisting  of  turpentine  and  lau- 
danum. This  uniformly  produced  a  discharge  of  uric  acid  gravel,  some- 
times amounting  to  more  than  four  ounces  in  two  or  three  days.  Possibly 
some  of  tliis  deposit  may  have  been  formed  as  discharged  under  the  consti- 
tutional influence  which  the  patient  had  learned  to  recognize,  assisted  pos- 
sibly by  opium;  but  the  bulk  probably  was  merely  dislodged  by  the  diu- 
retic. It  has  happened  to  me  more  than  once  to  find  on  post-mortem 
examination  so  large  a  collection  of  uric  acid  gravel  in  the  pelvis  of  tiie 
kidney  that  it  was  difficult  to  understand  how  it  could  have  thus  accu- 
mulated. Possibly  in  the  case  alluded  to  by  Di-.  Henry  some  such  lodgment 
luid  taken  place.  Small  discharges  of  uric  acid  gravel  under  the  influence 
of  turpentine  are,  however,  by  no  means  uncommon. 

Mixed  Urates. 

These  require  but  abrief  notice.  Uric  acid  in  combination  with  potash, 
soda,  ammonia,  and  occasionally  lime  in  varying  proportions,  the  potash 
generally  being  in  larger  quantity  than  the  soda  and  ammonia,  forms  the 
hest  known  of  all  urinary  deposits,  marked  as  it  is  by  the  obvious  char- 
acter of  ready  solubility  with  warmth.  Under  certain  circumstances  this 
forms  or  contributes  to  form  renal  calculi. 

Kenal  calculi  consisting  only  of  the  urates  are  exceedingly  rare — the 
museums  of  London  contain  but  two  specimens.  They  are  always  of 
small  size,  and  are,  as  far  as  I  am  aware,  peculiar  to  children.  The  Col- 
lege of  Surgeons  has  a  specimen  which  was  taken  from  the  body  of  an 
infant  only  four  months  old.  Such  calculi  are  light  or  yellowish  in  color, 
and  in  texture  soft  and  friable.  Their  peculiar  characteristic  is  their 
solubility  in  boiling  water.  It  is  probable  that  they  originate  in  the  de- 
position of  urates  in  the  kidney-tubes.  Lines  of  amorphous  lithates 
mixed  with  crystals  of  uric  acid  are  continually  found  in  the  straight 
tubes  of  children  who  die  soon  after  birth.  It  is  stated  that  the  dej)Osi- 
tion  is  very  rarely  found  in  still-born  children,  or  in  those  who  have 
breathed  for  less  than  twenty-four  hours,  but  that  it  is  generally  present 
between  the  first  and  tenth  days  of  extra-uterine  life.  It  is  probable,  as 
suggested  by  Virchow,  that  this  phenomenon  depends  upon  increased 

'  Analyses  of  Contrexeville  Water. 

^  On  Stomach  and  Renal  Diseases,  4th  edit.  p.  220. 

^  Med.-Chir.  Trans,  x.  p.  136. 


RENAL    CALCULI.  135 

production  of  uric  acid  by  the  tissue  change  consequent  on  the  establish- 
ment of  respiration,  wliile  there  is  no  proportionate  excretion  of  water 
to  hold  it  in  solution.  In  cases  in  whicli  the  tubes  are  thus  charged, 
red  sand  is  often  found  in  the  pelvis  and  bladder,  which  may  easily  fur- 
nish the  seed  of  a  calculus  and  explain  the  frequency  of  stone  in  child- 
hood. In  later  life  it  happens,  though  comparatively  rarely,  that  lines 
of  urates  are  found  in  the  cones:  possibly  this  may  sometimes  be  a 
post-mortem  occurrence  due  to  cooling  of  the  body,  and  consequent  jjre- 
cipitation  of  urates.' 

As  one  of  the  components  of  compound  renal  calculi  the  urates  are 
not  uncommon.  In  thirty-one  compound  calculi  in  the  museums  of 
London  the  urates  are  described  as  occurring  sixteen  times.  In  one  in- 
stance the  ordinary  urates  were  associated  with  urate  of  lime.  Dr.  Van- 
dyke Carter  found  the  urates  to  be  present  in  some  form  in  sixty-two 
per  cent  of  the  vesical  calculi  of  India,  forming  the  nucleus  in  fifty-six 
per  cent:  as  a  deposit  he  found  them  commonly  to  precede,  but  rarely 
to  follow  oxalate  of  lime;  sometimes  to  precede  uric  acid,  very  seldom 
succeeding  to  it.  Thus  the  urates  are  present  in  half  the  renal  stones, 
in  more  than  half  the  vesical.     . 

The  urates  occur  under  similar  circumstances  to  uric  acid,  and  may 
be  considered  as  having  the  same  practical  bearing. 

Xanthine,  C^H^N^O,. 

Xanthine" — xanthic,  or  uric,  oxide — i-esembles  uric  acid  in  composi- 
tion, from  which  it  differs  only  in  containing  one  atom  less  oxygen.  It 
is  believed  to  be  a  normal  constituent  of  the  urine,  though  existing  in  it 
in  very  small  amount.^ 

Xanthine  has  been  found  in  many  parts  of  the  body,  including  the 
liver,  spleen,  pancreas,  brain,  and  muscular  tissue.  It  has  been  found  in 
the  intestinal  concretions  of  animals,  and  in  guano. 

This  substance  forms  almost  the  rarest  of  known  urinary  calculi. 
Though  obviously  of  renal  origin,  it  has  not  yet  beenfound  in  the  kidney, 
and  therefore  is  not  strictly  included  within  the  scope  of  the  present 
Avork.  Since  Dr.  Marcet,  in  1817,  described  *' a  nondescript  calculus," 
which  he  termed  xanthic  in  reference  to  the  reaction  of  nitric  acid,  I  am 
aware  of  but  four  instances  in  which  urinary  calculi  of  this  nature  have 
been  discovered. 

Some  pisiform  concretions  passed  in  a  case  of  diseased  bladder  were 
shown  by  M.  Langier,  in  the  year  1829,  to  consist  of  tliis  substance. 

A  stone  removed  from  the  bladder  by  Professor  Langenbeck,  of  Han- 
over, a  portion  of  which  is  in  the  Museum  of  the  College  of  Surgeons 
and  another  portion  at  Guy's  Hospital,  the  composition  of  which  was 
detected  by  Professor  Stromeyer,  and  investigated  by  Liebig  and  Wohler, 
furnished  the  next  confirmation  of  Marcet's  observations.  A  fourth 
specimen  was  removed  from  the  urethra  of  a  boy  by  Professor  Dulk,  of 
Konigsberg,  and  the  fifth  and  last  was  found  by  Mr.  T.  Taylor,  in  tlie 

'  See  a  paper  on  "  Uric  acid  infarction  of  the  kitlnev."  by  Dr.  H.  Raphael  of 
Nevv_York,  reported  in  the  Brit.  Med.  Jonrn.  Dec.  ]0th,"l870^  p.  634. 

"  i~iay(j6i,  yellow,  from  tiie  lemon-colored  residue  after  solution  in  nitric  acid 
and  evaporation. 

^  Dr.  Tliudichum  lias  given  elaborate  directions  for  the  obtaining  of  xanthine 
from  Jiealthy  human  urine.     Path,  uf  the  Urine,  2d  edit.  p.  95. 


136  RENAL    CALCULI. 

Museum  of  the  College  of  Surgeons,  and  is  described  by  him  in  the 
"Pathological  Transactions"  for  the  year  1868.  The  stone  was  ex- 
tracted from  the  bladder  of  a  Mussulman  boy  by  Mr.  George  Coles,  a 
surgeon  in  the  service  of  the  East  India  Company:  it  had  been  in  tlie 
college  since  the  year  1851,  and  supposed  to  consist  chiefly  of  uric  acid. 

In  appearance  and  hardness  the  calculi  of  this  material  wiiich  have 
hitherto  been  discovered  have  closely  resembled  uric  acid.  Tiiey  are  de- 
scribed as  smooth  and  of  a  yellow  or  brownish  color.  Dr.  Mareet's  cal- 
culus had  a  reddish  cinnamon  color,  and  was  compact  and  laminated; 
Langenbeck's  was  also  laminated;  it  had  a  light-brown  color,  and  was 
externally  partly  polished,  of  an  earthy  texture.  This  calculus,  which  is 
the  largest  yet  known,  was  of  about  the  size  of  a  small  hen's  egg.  A 
peculiarity  of  the  material  is  its  acquirement  by  friction  of  a  waxy  or 
resinous  lustre. 

Calculi  of  this  material  are  readily  soluble  in  caustic  potash,  xanthine 
being  precipitated  by  acid  from  tlie  alkaline  solution  as  a  white  powder. 
Xanthine  is  soluble  in  nitric  acid  without  effervescence,  in  that  respect 
differing  from  uric  acid,  which  dissolves  with  copious  evolution  of  gas, 
the  solution  leaving  on  evaporation  a  lemon-colored  residue,  which  does 
not  become  red  when  acted  upon  by  ammonia. 

From  the  resemblance  of  xanthine  to  uric  acid,  whether  it  occur  as  a 
calculus  or  as  a  urinary  deposit,  it  is  probable  that  the  formation  is  not 
so  rare  as  is  supposed,  but  is  usually  mistaken  for  uric  acid. 

Clinically,  Avhat  has  been  said  regarding  the  formation  of  uric  acid 
nearly  applies  to  that  of  the  oxide,  since  the  oxide  is  but  the  acid  incom- 
plete by  the  want  of  its  last  stage  of  oxidation.  Dr.  Bence  Jones,  as  the 
prophet  of  oxygen,  was  of  opinion  that  with  more  of  it  the  production  of 
xanthine,  as  of  uric  acid,  can  be  exchanged  for  that  of  more  highly  oxi- 
dized normal  products,  and  recommends  the  restriction  of  fuel  in  the 
food,  with  resort  to  exercise,  warm  clothing,  alkalies,  and  iron.  Proba- 
bly the  formation  of  xanthine,  as  of  uric  acid,  is  not  to  be  fully  ex- 
plained until  more  is  known  of  its  relations  to  definite  organic  change. 

It  has  been  stated  that  xantliine  has  been  found  in  the  urine  as  the 
consequence '  of  bathing  in  sulpluirous  water,  and  of  the  inunction  of 
sulphur.  It  is  difficult  to  see  any  connection  between  sulphur  and  uric 
oxide;  if  the  statement  had  concerned  cystine  it  would  have  corresponded 
'better  with  our  expectations. 

Oxalate  of  Lime  and  the  Oxalic  Diathesis. 

Oxalate  of  lime  forms  the  hardest  and  most  insoluble  concretions 
to  which  the  human  body  is  liable.  They  are  soluble  only  in  strong 
acids,  not  in  any  alkaline  or  slightly  acid  solutions,  such  as  could  reach 
them  in  their  native  cavities.  They  appear  nearly  always  to  originate 
in  the  pelvis  or  tubes  of  the  kidney.  Crystals  of  oxalate  of  lime  of  the 
dumb-bell  shape  are  often  found  in  the  straight  tubes,  and  these  and 
octahedra  have  sometimes  been  seen  in  and  upon  casts.  Dr.  Beale 
noticed  this  in  particular  in  connection  with  the  suppression  of  urine  of 
cholera.  Of  all  urinary  dc})osits  the  oxalate  has  the  greatest  tendency  ta 
cohere — some,  like  the  amorphous  urates  and  phosphates,  adhere,  and 
that  with  much  readiness,  to  any  dead  surface,  but  they  seldom  concrete 
independently.     Uric  acid  concretes  independently,  and  the  oxalate  does- 

'  Beale,  Kidney  Diseases,  etc.,  edit.  3,  p.  374. 


RENAL    CALCULI. 


13T 


so  even  more  strikingly.  Numbers  of  octiihedra,  or  of  dumb-bells,  or  of 
irregular  lumps  derivable  from  the  latter,  are  often  found  under  the 
microscope  in  concrete  masses,  the  component  ])articles  sometimes  held 
together  by  a  translucent  web  like  a  film  of  structureless  mucus,  ormain- 
tainiug  their  contact  without  visible  means.  Each  mass  so  formed  is  a 
calculus  in  miniature,  and  needs  but  to  stay  in  one  of  the  urinary  cavi- 
ties to  acquire  concretion  perhaps  of  otiier  kinds.  I  have  before  me 
many  sketches  of  microscopic  concretions  formed  as  I  have  described, 
which,  however,  I  need  not  produce,  as  Dr.  Beaie  has  already  illustrated 
the  subject.'  This  tendency  of  the  oxalate  is  a  sufficient  explanation  of 
the  frequency,  upon  which  I  have  already  dwelt  (see  p.  124),  with 
which  stones  are  originated  by  it. 

The  material  has  a  strongly  crystalline  tendency.     Small  calculi  are 
often  developed  in  the  pelvis  of  the  kidney  which  consist  of  aggregations- 


^ 


(S) 


0(3) 


A  rare  form  of   oxalate    of  lime. 
Small  smooth  calculi,   "f  which  three 
ounces    were    found    within  a  dilated 
kidnej'.     (From  a  specimen  in  the  Col- 
lege of  Surgeons  ) 


Oxalate  of  lime  calculus  from  the 
kidney,  consisting  as  seen  in  section  of 
aggregated  spheres,  i  From  the  illustrated 
catalogue  of  the  College  of  Surgeons.) 


of  translucent  crystals,  which  look  as  if  they  belonged  to  the  mincrul 
instead  of  the  animal  kingdom.  In  traversing  the  ureter,  these  produce 
severe,  often  agonizing  pain.  The  divergent  groups  of  sharp  spines  or 
plates  become  the  centre  of  stratified  deposition,  wiience  arises  the  pecu- 
liar tubercnlated  exterior  by  which  oxalate  of  lime  calculi,  wliether  in  the 
kidney  or  bladder,  are  characterized.  The  spiked  or  bossed  exterior  is 
often  such  as  to  give  a  resemblance,  more  genuine  than  most  morbid 
similitudes,  to  a  blackberry  or  mulberry.  Though  when  oxalate  of  lime 
calculi  are  small  they  are  often  obviously  crystalline,  this  is  not  always 
the  case.  They  sometimes  take  the  aspect  of  black  or  dark  grains — 
black  gravel  as  it  has  been  termed — wiiich  much  resemble  poppy-seeds. 
Sometimes  they  are  of  a  light  color.  At  the  College  of  Surgeons  are  a 
number  of  renal  concretions  of  oxalate  of  lime,  which  consist  of  minute 
polished  spherules,  which  but  for  their  faint  yellowish  tint  might  pass 
for  a  collection  of  small  pearls. 


^Kidney  Diseases,  etc.,  3cl  edit,  plate  xxxiii.  p.  378. 


138 


RENAL    CALCULI. 


Often  these  concretions  attain  a  considerable  size  in  tlie  kidney, 
though  they  do  not  reach  the  enormous  bulk  occasionally  presented  by 
uric  acid,  and  often  by  the  phosphates.  One  of  the  largest  renal  calculi 
of  oxalate  of  lime  which  I  have  met  with  is  represented  (woodcut,  p. 
137).     It  belongs  to  the  College  of  Surgeons. 

Sometimes  a  large  number  of  calculi  of  this  substance  are  found  in 
one  kidney,  where  their  angular  forms  are  well  adapted  to  cause  irrita- 
tion. These  calculi,  from  their  Inirdness  and  close  texture,  take  a  high 
])olish,  and  with  their  irregular  stratification  and  variegated  color  often 
resemble  agates,  and  might  well  be  applied  to  ornamental  purposes,  were 


Remarkably  pointed  calculi,  consisting  of  oxalate,  with  a  small  proportion  of  phosphate  of 
lime.  The  kidney  in  which  they  were  found  was  ruptured  by  the  fall  of  a  brick  upon  the  loins. 
(8t.  George's  Hospital.) 

the  diseases  of  human  beings  like  those  of  oysters  resorted  to  for  the  pro- 
duction of  jewelry. 

It  is  probable  that  no  varieties  of  renal  calculi  cause  so  much  i^ain  as 
oxalate  of  lime,  tbougli  from  the  fact  that  they  are  less  often  disposed 
Avith  bilateral  symmetry,  they  are  not  such  frequent  causes  of  fatal  sup- 
pression of  urine  as  are  concretions  of  uric  acid. 

AVhat  has  been  termed  the  oxalic  acid  diathesis  has  been,  since  it  was 
first  brought  into  notice  by  Prout,  the  subject  of  much  discussion.  The 
deposition  of  oxalate  of  lime  in  the  urine  lias  been  regarded  by  some  as  a 
sign  of  the  gravest  disturbance  of  jiealth,  by  others  as  of  comparative 
insignificance.     There  is  no  doul)t  that  ci-vstals  of  oxalate  of  lime  are 


RENAL    CALCULI.  139 

often  produced  in  urine  by  changes  which  have  occurred  subsequent  to 
its  secretion;  Avhile,  on  the  other  hand,  it  must  be  admitted  that  the 
habitual  production  of  these  crystals  is  often  associated  with  a  condition 
of  nervous  depression  akin  to  that  which  attends  the  excessive  secretion 
of  lime  in  any  shape. 

So  much  as  concerns  the  formation  and  prevention  of  concretions  of 
the  oxalate  may  be  briefly  stated.  Oxalate  of  lime  is  precipitated  only  in 
acid  urine.  Oxalic  is  closely  allied  to  uric  acid,  uric  acid  being,  it  is 
said,  convertible  by  the  addition  of  oxygen  and  water  into  oxalic  acid  and 
urea.  Dr.  Owen  Eees  has  shown  that  by  virtue  of  some  such  change 
when  urine  containing  urates  is  heated,  oxalate  of  lime  is  produced.  He 
believes  that  this  conversion  is  of  very  frequent  occurrence,  and  is  in  fact 
the  only  source  of  oxalic  acid  in  the  urine. 

Whether  or  no  oxalic  acid  in  the  urine  is  usually  thus  produced,  we 
have  evidence  that  it  may  also  appear  in  this  secretion  after  having  been 
swallowed,  and  on  the  strength  of  this  possibility  persons  prone  to  the 
deposition  of  the  oxalate  have  been  made  to  abstain  from  rhubarb  and 
sorrel,  too  often  an  ineffectnal  injunction,  for  practically  the  develop- 
ment of  the  salt,  as  will  be  presently  shown,  is  a  question  more  of  lime 
than  of  oxalic  acid. 

That  this  acid  is  more  oftea  developed  within  the  organism,  whether 
in  the  urinary  cavities  or  elsewhere,  than  introduced  from  without  is 
evident  from  the  frequent  and  abundant  discharge  of  it,  though  all  food 
known  to  contain  it  be  excluded.  According  to  Dr.  Bence  Jones,  the 
''oxalic  diathesis,"  like  other  forms  of  acidity,  is  a  result  of  the  insuffi- 
cient action  of  oxygen  and  the  arrest  at  the  stage  of  oxalic  acid  of  the 
process  of  oxidation,  by  whicli  the  hydrocarbons  of  food  should  be  trans- 
muted into  carbonic  acid  and  water. 

But  what  is  of  more  practical  importance  than  this  hypothetical  de- 
velopment of  the  acid  is  the  influence  of  the  base.  Given  excess  of  lime 
in  the  urine,  oxalic  acid,  come  it  from  whence  it  may,  is  seldom  wanting. 
Whether  it  be  that  an  abundance  of  lime  accelerates  the  process  of 
decomposition  by  which  oxalic  acid  is  made  from  other  urinary  substan- 
ces, or  whether  this  acid  is  more  generally  secreted  with  the  urine  than 
has  hitherto  been  thought,  the  excess  of  lime  only  bringing  into  view 
what  previously  existed,  from  one  of  these  causes  or  some  other  it  is  cer- 
tain that  if  much  lime  be  passed  with  the  urine,  whether  as  a  consequence 
of  the  excessive  ingestion  of  this  earth,  or  otherwise,  some  of  it  will 
usually  appear  as  oxalate. 

If  chloride  of  calcium  be  added  to  healthy  urine,  crystals  of  oxalate  of 
lime  will  generally  be  thrown  down.  Similarly,  if  lime  in  the  form  of 
lime-water  or  oxalate  of  lime  be  administered  for  a  few  days  to  a 
liealthy  person  the  lime  will  reappear  in  the  urine,  partly  as  phos- 
phate, and,  so  long  as  the  urine  remains  acid,  partly  as  oxalate.  A 
similar  production  of  oxalate  of  lime  probably  occurs  from  tlie  con- 
tinued drinking  of  water  highly  ciiarged  with  lime ;  hence  the 
known  frequency  of  urinary  calculi  in  limestone  districts.  It  may  bo 
generally  stated  that  when  the  urine  contains  excess  of  lime,  if 
the  secretion  be  normally  acid,  much  of  the  lime  will  appear  as  oxalate;  if 
it  be  slightly  acid  or  neutral,  as  acid  or  crystalline  phosphate;  if  alkaline, 
as  amorphous  or  basic  phosphate.* 

'  For  further  particulars  upon  the  action  of  lime-salts  upon  the  urine,  I  may 
refer  to  some  otjservations  I   made  in  conjunction  with   Dr.  Bence  Jones,  the 


140  RENAL    CALCULI. 

The  practical  issues  of  wliat  has  been  stated  with  regard  to  oxalate  of 
lime  may  be  briefly  explained. 

When  tiiis  deposit  is  formed  persistently  in  copious  clear  and  pale 
urine,  it  may  generally  be  regarded  as  the  result  of  secretion,  and  a  sign 
of  a  constitutional  state.  When  it  is  found  in  high-colored  or  lithatic 
urine,  it  may  possibly  have  resulted  from  a  decomposition  of  urates,  and 
be  without  clinical  significance. 

Accord  i  ng  to  Dr.  Prou  t,  the  oxalic  diathesis  is  more  common  i  n  men  than 
in  women,  it  affects  chiefly  persons  of  either  a  sanguine  or  a  melancholic 
tem})erament,  it  is  often  associated  with  affections  of  the  skin,  and  it  is 
apt  to  be  developed  by  residence  in  a  damp  or  malarious  district.  The 
association  of  oxalate  of  lime  and  malaria  is  of  interest  in  connection 
with  intermittent  hasmaturia,  a  disease  which  is  connected  with  ague, 
and  in  which  crystals  of  oxalate  almost  invariably  abound.  Often  the 
de[)Osition  is  associated  with  flatulent;  dyspepsia,  and  with  nervous  depres- 
sion and  irritability,  though  it  is  by  no  means  certain  that  the  state  of 
the  nervous  system  is  not  more  often  the  cause  than  the  consequence  of 
the  disturbance.  Dr.  Bence  Jones  thus  describes  the  symptoms  of  the 
**  oxalic  diathesis  "  : — 

''The  most  common  symptom  i?  flatulent  dyspejisia;  frequently  before 
food  considerable  uneasiness  is  felt  and  eructation  occurs.  Eating  for  a 
time  removes  the  symptoms,  only  to  return,  in  an  hour  or  two,  with  in- 
creased intensity.  The  pain  sometimes  is  so  severe,  persistent,  or  inter- 
mitting, that  it  can  only  be  produced  l)y  actual  cramp  of  the  muscular  coat 
of  the  stomach.  This  state  of  suffei'ing  may  last  from  half-an-hour  to 
three  or  four  hours,  and  then  cease  to  return  for  some  days,  months,  or 
years.  In  the  urine  the  presence  of  oxalate  of  lime  may  be  suspected 
when  sudden  changes  in  the  quantity  made  in  twenty-four  hours  are  ob- 
served. Usually  an  increased  urgency  and  frequency  of  making'  Avater 
accompanies  this  increased  flow,  and  there  is  a  general  feeling  of  irrita- 
bility of  the  nervous  system,  exaggerating  external  and  internal  an- 
noyances to  a  degree  far  beyond  that  to  which  they  would  give  rise  if  no 
dyspepsia  existed." 

It:  is  certain,  however,  that  while  such  disturbances  ai-e  often  found 
in  conjunction  with  the  deposition  of  the  oxalate,  they  may  equally  occur 
as  a  result  of  tlie  gouty  condition  without  any  production  of  oxahite  of 
lime  in  the  urine,  and  further  tiiat  oxalate  of  lime  may  be  precipitated 
abundantly  in  persons  who  appear  to  be  in  perfect  health,  and  neitlier 
present  tlie  symptoms  nor  possess  the  constitutional  characters  which 
have  been  associated  with  the  oxalic  diathesis.' 

The  oxalic  diafhesis  is  a  condition  whicli  has  been  considered  too 
much  as  an  isolated  one,  instead  of  being  connected,  as  it  is,  with  that 
tendency  to  pass  earthy  salts  in  excess  whicli  is  so  constantly  associated 
with  an  active,  restless,  or  irritated  nervous  system.  Oxalic,  like  other 
earthy  deposits,  are  found  in  persons  of  a  nervous  temperament,  who 
have  pale  complexions,  pass  abundant  light-colored  urine,  and  for  the 
most  part  lead  studious  and  sedentary  lives. 

As  to  the  treatment  of  the  oxalic  diathesis,  or  in  other  words,  the  pre- 

results  of  which  have  been  published  by  him  in  the  Trans,  of  the  Chemical 
Society. 

'  It  may  be  added  that  the  presence  of  oxalate  of  lime  in  the  urine  of 
children  is  often  associated  with  noturnal  incontinence. 

^  For  some  valuable  information  upon  this  subject  I  may  refer  to  Dr.  Roberts's 
work  on  Urinary  and  Renal  Diseases. 


RENAL    CALCULI.  141 

vention  of  tlie  concretion  of  oxalate  of  lime,  it  is  obviously  advisable  to 
inhibit  hard  water,  and  by  way  of  theoretic  accuracy,  the  vegetable 
vehicles  of  oxalic  acid,  rhubarb  and  sorrel.  If  there  be  any  tendency  to 
concretion,  tliefree  use  of  distilled  or  soft  water  is  indicated. 

Dr.  Front,  seconded  in  this  respect  by  Dr.  Bence  Jones,  held  that  the 
diet  should  approximate  to  that  now  commonly  enforced  in  diabetes,  of 
which  meat  and  s[)irit  and  water  form  the  staples.  Sugai-,  according  to 
Dr.  Prout,  should  be  entirely  prohibited.  French  cookery,  "by  wliich 
animal  matters  are  reduced  to  a  semi-fluid  or  pultaceous  mass,"  agrees 
better,  according  to  the  same  authority, than  the  "solid  cliops  or  steaks 
of  this  country."  Dr.  Basham,  however,  nowise  assents  to  these  views. 
He  commends  "good  English  fare,  neither  a  vegetable  diet  nor  an  ani- 
mal diet  prevailing,"  and  I  think  that  experience  is  with  Dr.  Basham. 
Persons  who  pass  lime  freely,  though  often  dyspeptic,  need  a  liberal  diet, 
one  not  too  narrowly  restricted.  Plainly  cooked  meat,  without  the  ex- 
clusion of  vegetables,  and  with  a  little  non-saccharine  wine — claret  or 
light  sherry — may  be  generally  resorted  to,  while  in  some  cases  dis- 
tinct benefit  will  follow  from  the  occasional  admission  of  port  wine  or 
bitter  ale. 

It  is  scarcely  necessary  to  insist  on  the  use  of  fresh  air  and  free  exer- 
cise in  this  condition,  whether  regarded  as  one  of  imperfect  assimilation 
or  nervous  disturbance. 

As  medicine,  nitro-muriatic  acid  has  been  reputed  since  the  days  of 
Prout  to  prevent  the  deposition  of  oxalate  of  lime,  and  there  can  be  no 
doubt  that  the  reputation  is  deserved.  Strychnia,  with  or  without  the 
acid,  is  often  of  the  greatest  use,  apparently  correcting  the  conditions  of 
nervous  system  in  which  the  tendency  takes  its  rise.  Quinine  and  iron 
are  less  generally  useful.' 

Phosphatic  Calculi  and  the  Phosphatic  Diathesis. 

Three  varieties  of  calculi  are  found  in  the  kidney,  consisting  of 
earthy  or  ammoniacal  phosphates — the  calcic  phosphate,  the  ammonio- 
magnesic  phosphate,  and  the  fusible  calculus,  which  is  a  mixture  of  the 
two. 

Calcic  liliosphate,  or  bone  earth,  CajP^O^,  in  an  unmixed  state,  is  rare 
as  a  urinary  concretion.  Calculi  of  this  material  are  generally  chalky 
in  appearance,  or  with  a  faint  brownish  tinge.  They  are  often  laminated 
concentrically,  Avhile  their  outer  surfaces  are  polisiied.  The  material 
cannot  ,be  fused  with  the  blowpipe.  It  dissolves  readily  in  hydro- 
chloric acid,  from  which  solution  it  is  precipitated  in  a  gelatinous  state 
by  ammonia. 

A  deposit  of  this  nature,  derived  as  it  is  from  urine  which  is  alkaline, 
but  not  ammoniacal,  is  very  apt  to  be  succeeded  by  the  triple  or  mixed 
phosphate,  which  ammoniacal  urine  induces,  for  tiie  obvious  reason  that 
alkaline  urine  is  apt  to  become  ammoniacal.  Stones  of  tliis  nature, 
therefore,  seldom  or  never  attain  a  large  size  uncomplicatt'd  by  other  de- 
posits. Indeed,  stones  of  pure  phosphate  of  lime  of  any  size  are  among 
the  rarities  of  pathology.  The  largest  and  best-described  collections  in 
London,  namely,  those  at  the  College  of  Surgeons  and  St.  George's  Hos- 
pital, contain  no  example. 

When  the  concretion  of  phosphates  is  established,  though  one  kind  of 

'  In  relation  to  the  phosphatic  diatliesis  see  also  the  chapter  on  Phosphuria. 


142 


BENAL   CALCULI. 


phosphatic  deposit  may  be  overlaid  by  another  or  by  carbonate  of  lime^ 
it  is  almost  unknown  for  uric  acid  or  oxalate  of  lime  to  be  deposited, 
bearing  out  the  statement  of  Dr.  Marcet,  that  the  phosphatic  diathesis  is 
never  succeeded  by  any  other.' 

The  ammonio-magnesic  or  triple  phosphate  (H^NMgPOJ*  is  the  pro- 
duct of  ammoniacal  urine.  It  rarely  occurs  as  a  primary  deposit,  except- 
ing as  an  intrustation  upon  a  diseased  surface.  It  forms  a  coating  upon 
stones  of  every  sort,  being  deposited  wherever  the  primary  concretion 
causes  enough  mucous  irritation  to  make  the  urine  in  the  pelvis  ammo- 
niacal by  the  admixture  of  diseased  secretion.  The  substance  is  white, 
soft,  and  friable,  of  loose  texture,  seldom  laminated,  often  sparkling  with 
crystalline  grains.  It  fuses  with  difficulty  before  the  blowpipe,  giving  an 
ammoniacal  odor.  Dilute  acids  dissolve  it  readily,  and  the  solution  when 
neutralized  with  ammonia  deposits  it  again  in  a  crystalline  form. 


^^.v 


Two  calculi  from  the  same  kidney,  the  smaller  of  which  is  entirely  composed  of  triple  phos- 
phate; the  larger  externally  of  the  mixed  phosphates.    (St.  George's  Hospital.) 

The  general  aspect  of  calculi  largely  composed  of  this  material  may  be 
learned  from  the  accompanying  woodcuts. 

The  first  represents  two  calculi  which  lay  together  in  the  same  kid- 

'  Dr.  Roberts  mentions  a  calculus  (probably  vesical)  in  which  uric  acid  alter- 
nates with  bone  earth;  this,  however,  is  exceedingly  rare. 

*  I  have  known  as  an  exceptional  circumstance  the  ammonio-magnesian  phos- 
phate to  be  deposited,  and  that  most  copiously,  and  immediately  upon  the  emis- 
sion of  the  urine,  when  that  secretion  has  been  alkaline,  but  not  appreciably 
ammoniacal  or  decomposed.  A  striking  instance  of  this  occurred  in  a  case  of 
tubal  nephritis,  in  which  recovery  took  place.  The  ammonia  was  of  course  pres- 
ent in  the  urine,  though  not  in  a  volatile  form,  probably  the  result  of  secretion, 
not  of  decomposition.  It  may  be  noticed  also  that  there  are  special  circumstances 
in  which  crystals  of  the  same  kind  are  habitually  found  in  acid  urine,  though  not 
formed  in  it.  The  urine  in  tlie  pelvis  of  one  kidney  may  be  ammoniacal  from 
stone  or  other  local  disease,  while  that  in  the  other  kidney  is  healthy,  and  the 
mixture  in  the  bladder  acid.  The  ammoniacal  crystals  may  escape  complete  solu- 
tion in  the  bladder,  but  present  in  the  corrosion  of  their  outlines  signs  of  partial 
solution,  which  may  be  generally  taken  as  evidence  of  unilateral  disease. 


RENAL    CALCULI. 


143 


ney,  the  larger  of  which  is  partly,  and  the  smaller  entirely,  composed  of 
the  triple  phosphate.  The  smaller  stone,  in  being  thus  solely  composed 
of  triple  phosphates,  hardly  need  be  regarded  as  an  exception  to  the  rule 
that  this  deposit  is  always  consequent  upon  some  other,  since  the  smaller 
stone  was  probably  secondary  to  the  larger,  and  resulted  from  the  mucous 
disturbance  it  set  up.  A  renal  stone  of  almost  pure  triple  phosphate, 
which  weighed  seven  and  a  half  ounces — one  of  the  largest  on  record — is 
represented  in  the  annexed  woodcut.  The  calculus  was  taken  from  the 
body  of  a  daughter  of  the  well-known  Sir  Richard  Steele;  the  kidney  had 
been  reduced  to  a  mere  cyst. 

Mixed  phosphates,  or  the  fusible  calculus  of  Wollaston,  consisting  of 
a  mixture  in  variable  propor- 
tions of  the  calcic  and  the  am- 
monio-magnesic  phosphates, 
is  far  more  frequently  met 
with  than  either  of  its  com- 
ponents alone.  It  is  deposited 
in  similar  circumstances  to 
the  triple  phosphate  by  alka- 
line and  ammoniacal  urine, 
in  general  connection  with 
inflamed  mucous  membrane. 
It  incrusts  foreign  bodies, 
calculi  of  all  kinds,  morbid 
growths,  and  roughened  or 
inflamed  membrane.  It  col- 
lects about  urinals,  or  wher- 
ever urine  is  allowed  to 
putrefy.  A  quantity  of  it, 
which  had  been  scraped  from 
the  bottom  of  a  chamber 
vessel  which  had  been  seldom 
emptied,  and  never  cleaned, 
was  once  sent  to  me  from  a 
remote  part  of  Great  Britain. 
The  urine  had  been  passed, 
by  a  gentleman  who  had 
symptoms  of  renal  calculus, 
but  the  collection  of  this 
deposit  indicated  only  that 
his  urine  had  been  allowed 
to  decompose,  subsequent  to 
its  emission.  The  same  pro- 
cess may,  of  course,  occur 
within  the  urinary  cavities, 
as  well  as  externally  to  them. 

Calculi,  consisting  mainly  of  this  material,  vary  much  in  size,  often 
attaining  a  great  bulk.  Tiiey  are  often  of  very  irregular  shape,  curved 
and  branched,  so  as  to  follow  the  shape  of  the  pelvis.  In  their  irregular 
and  fantastic  shapes  and  earthy  white  outsides  these  calculi  often  resemble 
rough  flints  fresh  the  chalk.  They  are  loose  and  friable  generally,  but 
not  always,  showing  stratification  on  section.  Their  substance  often 
sparkles  with  minute  crystals  of  triple  phosphate.  It  fuses  readily  before 
the  blowpipe;  it  is  soluble  in  dilute  acids;  from  its  solution  animonium- 


Renal  calculus,  weighing  seven  and  a  half  ounces. 
Nearly  pure  phosphate  of  magnesia  and  ammonia.  The 
central  part  is  confusedly  crystallized,  the  rest'lamin- 
ated.  (I'roui  the  illustrated  catalogue  of  the  College  of 
Surgeons.) 


iJrJ:  RENAL    CALCULI. 

oxalate  separates  calcic  oxalate,  and  pure  ammonia  throws  down  ammonio- 
magnesic  phosj)hate. 

When  calculi  are  of  large  size,  whatever  their  internal  structure  may 
be,  they  are  almost  invariably  coated  either  with  mixed  or  triple  phos- 
phate. 

A  good  specimen  of  a  renal  stone  composed  externally  of  the  mixed 
phosphates  is  seen  in  woodcut  (page  142). 

Of  late  years  much  light  has  been  thrown  upon  the  precipitation  of 
the  earthy  and  ammoniacal  i)liosphates.  Prout — the  accuracy  of  whose 
observations  of  disease  must  give  his  work  permanent  value,  however  time 
may  modify  his  chemical  theories — thought  that  the  deposition  of  the 
triple  or  earthy  phosphates  was  necessarily  owing  to  their  superabundant 
secretion  in  the  urine,  and  associated  grave  sym})toms  of  nervous  pros- 
tration and  irritability  Avith  their  ])resence  as  urinary  sediments.  It  is 
probable  that  Prout.  did  not  over-estimate  the  clinical  significance  of 
these  deposits,  though  later  observations  have  shown  tliat  the  earthy  phos- 
])hates,  though  not  existing  in  more  than  their  natural  amount,  may  be 
deposited  by  urine  simply  because  it  is  wanting  in  acidity,  and  that  the 
ammoniacal  salt  is  the  product  of  decomposition,  not  of  secretion.  Phos- 
phate of  lime  is  soluble  in  acid,  but  not  in  alkaline  urine,  and  is  thrown 
■down  wherever  the  urine  loses  its  acidity.  From  urine  which  is  neutral 
or  barely  acid  the  crystalline  or  acid  phosphate  is  deposited.  Decidedly 
.alkaline  urine  deposits  the  neutral  or  amorphous  phosphate.  80  long  as 
the  urine  remains  free  from  ammonia  the  lime-salt  will  be  thrown  down 
without  any  ammoniacal  admixture,  and  a  stone,  should  one  form,  will 
consist  of  phosphate  of  lime  unmixed  with  the  triple  phosphate — a  rare 
variety  of  calculus.  Urine  alkaline  only  from  fixed  alkali  is  generally 
unconnected  with  any  local  irritation  in  the  urinary  tract,  and  is  unmixed 
with  mucus.  The  sediment,  therefore,  is  loose  and  powdery,  and  has 
little  tendency  to  cohere  into  calculi.  If  the  urine  be  ammoniacal,  the 
deposit  will  be  mixed,  containing  ammonio-magnesic,  in  addition  to  the 
•calcic,  salt-  Possibly  under  such  circumstances  the  ammonio-magnesian 
salt  may  be  in  much  the  larger  proportion,  and  may  concrete  almost  by 
itself.  The  concretion  is  facilitated  by  the  mucus,  which  in  such  cases 
is  alwa^'s  present.  AVitli  this  dependence  of  phosphatic  calculi  upon 
alkalescence  of  urine,  it  is  necessary  to  revert  to  the  conditions  under 
which  fixed  and  ammoniacal  alkalinity  occur. 

Urine  alkaline  from  fixed  alkali  has  been  so  secreted.  It  is  secreted 
ammoniacal  only  in  exceptional  circumstances.  If  ammoniacal,  it  has 
almost  invariably  become  so  subsequent  to  secretion  as  a  result  of  putre- 
factive change,  and  the  conversion  of  urea  into  carbonate  of  ammonia. 
"When  urine  is  pi'imarily  alkaline  from  fixed  alkali,  it  the  more  retidily 
takes  on  ammoniacal  decomposition,  for  which  reason  the  dej)osition  of 
the  calcic  is  likely  to  be  early  succeeded  by  that  of  the  mixed  i)hosphate. 

The  urine  may  be  alkaline  from  fixed  alkali,  either  because  the  alka- 
lies or  lime  are  in  excess,  or  the  acid,  especially  the  phosphoric,  deficient. 
The  condition  is  usually  associated  Avith  a  depressed  state  of  health, 
especially  involving  circumstances  of  nervous  depression.  Many  condi- 
ditions  of  serious  chronic  disease  have  been  mentioned  as  thus  accom- 
panied— phthisis,  dyspei^sia,  chronic  vomiting,  gout,  chlorosis,  etc.  It 
sometimes  happens  that  the  urine  is  thus  alkaline  at  an  advanced  stage  of 
granular  degeneration  of  the  kidney;  under  these  circumstances  the  con- 
dition is  one  of  evil  augury,  as  it  appears  to  depend  upon  defective 
elimination  of  phosphoric  aciil.     Apart  from  states  of  health,  the  urine 


RENAL    CALCULI.  145 

may  obviously  be  rendered  alkaline  by  medicines  containing  potash  or 
soda,  their  carbonates  or  their  vegetable  salts,  which  in  the  body  are  con- 
verted into  carbonates,  or  by  fluids  containing  lime,  such  as  lime-water, 
or,  as  has  been  used  experimentally,  the  solution  of  the  acetate. 

Fixed  alkalinity  of  urine  as  a  morbid  condition,  unconnected,  that  is, 
with  food  or  medicine,  suggests  a  treatment  of  a  generally  tonic  char- 
acter, in  which  mineral  acids,  perchloride,  or  other  salts  of  iron,  and 
quinine,  strychnia,  or  other  vegetable  bitters  are  included.  The  condi- 
tion, however,  comparatively  seldom  occurs  unconnected  with  some  other 
morbid  state,  on  which  the  management  of  the  patient  will  chiefly  dejiend. 

Ammoniacal  urine  becomes  so,  as  a  rule,  in  consequence,  as  has  been 
stated,  of  change  subsequent  to  secretion,  and  is  therefore  a  sign  of  dis- 
eased urinary  cavities,  rather  than  of  alteration  of  blood.  Instances  have, 
however,  been  recorded  in  which  there  is  reason  to  believe  that  the  urine 
has  been  secreted  ammoniacal.'  I  could  not  doubt  that  this  was  so  in  the 
case  of  a  feeble  old  lady  who  often  passed  ammoniacal  urine  when  more 
than  usually  debilitated,  the  normal  condition  of  the  urine  being  as  often 
restored  by  mineral  acids  and  tonic  treatment.  The  urine  of  advanced 
renal  disease  often  has  a  fishy  and  distinctly  ammoniacal  smell,  together 
with  an  alkaline  reaction,  and  must  be  presumed  to  have  been  so  secreted 
when,  as  often  happens,  the  cavities  and  passages  are  free  from  disease. 

Dr.  Graves  ^  mentions  two  instances  in  which  carbonate  of  ammonia 
was  apparently  present  in  urine  when  secreted.     It  may  be  accepted  as  a 
rule  which  has  few  exceptions  that  whenever  the  urine  is  ammoniacal  to 
the  smell,  or,  in  other  words,  contains  carbonate  of  ammonia,  it  has  be- 
come so  in  the  bladder  or  pelvis  of  the  kidney  as  the  result  of  local  dis- 
ease, comprising  either  retention  of  urine  or  inflammation  of  the  urinary 
membrane,  or  both.    Urine  retained  in  the  bladder  by  mechanical  obstruc- 
tion or  from  loss  of  expulsive  power  decomposes,  becomes  ammoniacal,  sets 
up  thereby  vesical  inflammation,  and  tnus  becomes  mingled  with  morbid 
mucous  products,  which  intensify  its  putrescence,  and  add  to  its  irritat- 
ing jiroperties.    The  urinary  mucous  membrane  is  apt  to  discharge,  when 
irritated  by  calculi,  morbid  growths,  or  retained   urine,  alkaline  fluid, 
which,  by  acting  as  a  ferment,  causes  decomposition.    From  this  or  some 
similar  reason,  urine  mixed  with  the  products  of  mucous  inflammation 
rapidly  decomposes  and  acquires  ammonia.     A  calculus,  whatever  its 
composition,  if  it  be  such  as  to  cause  much  mucous  irritation,  is  apt  to 
be  bathed  with  ammoniacal  urine  intermixed  with  mucous  or  muco- 
purulent flux.     The  earthy  and  triple  phosphates  are  necessarily  pre- 
cipitated, while  the  tenacious  mucus  binds  them  together  into  a  coherent 
form,  thus  supplying  all  the  conditions  needed  for  the  formation  and  re- 
tention of  calculous  matter.     The  precipitate  supplies  the  stone,  and  the 
mucus,  so  to  speak,  adds  the  mortar.     Calculi  of  vast  size  thus  accumu- 
late.    It  used  to  be  thought  that  under  some  circumstances  the  urinary 
mucous  membrane  actually  secreted  earthy  matter,  instead  of,  as  now  un- 
derstood, only  causing  its  precipitation.     The  abundance  of  thcphosphatic 
accumulation   in  some   cases  is  enough  to  suggest  that  there  may  be 
truth  in  the  old  view;  but  I  am  not  aware  that  any  observations  have 
oeen  made  as  to  the  amount  of  earthy  salts  in  urinary  mucus,  nor  would 
it  be  easy  to  obtain  it  in  sufficient  quantity  for  analysis  unmixed  with 
urine. 


10 


'  Urinary  and  Renal  Diseases,  p.  29. 

'  Clinical  Lectures,  2d  edit.,  vol.  ii.  p.  272. 


14:6  RENAL    CALCULI. 

Any  source  of  irritation  in  the  pelvis,  or  any  means  by  which  the- 
urine  is  rendered  ammoniacal,  may  determine  the  formation  in  this  situ- 
ation of  a  mixed  phosphatic  calcuhis.  Probably  most  calculi  of  this  kind 
take  their  rise  in  a  concretion  of  oxalate  of  lime  or  uric  acid.  Others 
originate  in  a  clot  of  blood  or  a  mass  of  agglutinated  mucus.  A  phos- 
phatic calculus  in  the  kidney  may  t.rise  from  a  state  of  urine  set  up  by  a 
stone  in  the  bladder.  A  preparation  recently  added  to  the  collection  at 
St.  George's  Hospital  may  serve  as  an  illustration.  The  bladder,  that  of 
a  child,  contains  a  large  uric  acid  stone  partially  encrusted  with  phos- 
phates. Each  kidney  contains  an  irregular,  elongated  calculus  of  mixed 
phosphates  accurately  moulded  to  the  shape  of  the  pelvis.  It  would 
seem  that  the  uric  acid  stone  developed  in  the  bladder  until  it  at  last  caused 
by  its  irritation  an  ammoniacal  condition  of  urine,  and  became  conse- 
quently coated  with  phosphates.  The  ammoniacal  urine  regurgitated, 
or  the  mucous  inflammation  travelled  upwards  until  the  ammoniacal 
condition  prevailed  in  the  pelves.  Precipitation  then  took  place  in  both 
kidneys,  until  the  cavity  of  each  was  filled  with  the  earthy  deposit 
almost  as  regularly  as  if  plaster  of  Paris  had  been  artistically  poured  in. 

The  ammoniacal  state  of  urine  connected  with  paralysis  of  the  blad- 
der from  disease  of  the  spine  or  cord,  or  the  vesical  inaction  which  may 
accompany  typhus  and  other  febrile  states,  is  occasionally  productive  of 
phosphatic  calculi  in  the  bladder,'  and  possibly  sometimes  also  in  the 
kidney.  Dr.  Thudichum  ^  analyzed  a  stone  which  had  been  formed 
in  the  bladder  as  the  result  of  typhus,  and  found  it  to  consist  of  the 
ammouio-magnesic  phosphate  with  but  a  minute  admixture  of  the  calcic 
phosphate. 

When  the  urine  is  ammoniacal,  the  first  thing  to  be  done  is  to  inquire 
into  the  condition  of  the  bladder,  prostate,  and  urethra  with  a  view  to 
removing  any  stone  or  other  source  of  irritation  or  obstacle  which  may 
be  found.  I  do  not  propose  to  trench  upon  the  domain  of  surgery,  but 
may  briefly  say  that  the  indication  is  to  secure  a  free  exit  for  the  urine 
in  such  a  manner  as  not  to  exasperate  existing  inflammation  or  introduce 
septic  agents  into  the  bladder.  The  frequency  with  which  fatal  renal 
suppuration  follows  the  use  of  the  catheter  makes  the  instrument  one  of 
the  most  deadly  of  all  the  means  of  offence  possessed  by  the  surgeon. 
There  can  be  no  doubt  that  antiseptic  precautions  lessen  the  danger  (see 
p.  13). 

A  free  exit  to  the  putrefying  urine  having  been  secured,  the  mucous 
membrane  may  right  itself,  and  nothing  more  may  be  needed.  Should 
the  cystitis  persist,  great  good  may  be  sometimes  done  by  acids,  of  which 
the  mineral,  nitric  and  nitro-hydrochloric,  answer  best.  Such  remedies 
by  the  mouth  correct  the  alkalinity  of  the  urine,  and  take  away  its  most 
irritating  property,  by  preventing  the  evolution  of  ammonia.  In  some 
cases  vesical  injections  of  nitric  acid  and  quinine  may  be  called  for, 
while  pareira  and  uva  ursi  form  useful  adjuncts.  Good  living  is  gener- 
ally necessary. 


'  See  the  remarkable  case  of  Sir  Walter  Ogilvie,  recorded  in  the  catalogue  of 
calculi  belonging  to  the  College  of  Surgeons,  part  i.  p.  116.  An  attack  of  para- 
plegia, consequent  upon  an  accident,  was  succeeded  by  the  formation  in  the 
bladder  of  a  calculus  of  mixed  phosphates,  which  eventually  attained  the  weight 
of  forty-four  ounces. 

2  Pathology  of  the  Urine,  2d  edit.  p.  335. 


kenal  calculi.  147 

Calcic  Carbonate. 

Concretions  of  carbonate  of  lime  are  often  formed  in  the  prostatic 
ducts,  whence  they  escape  into  the  bladder  or  with  the  urine  in  the  guise 
of  vesical  calculi.  Whether  such  stones  ever  originate  in  the  cavity  of 
the  bladder  is  yet  uncertain:  we  have  evidence  that  they  sometimes  do  so 
in  the  kidney.  "Whatever  their  actual  origin,  they  present,  as  obtained 
from  the  urinary  cavities,  tolerably  uniform  ciuiracteristics.  They  are 
usually  numerous,  of  small  size,  and  more  or  less  spherical  shape,  often 
comparable  to  peas  or  hemp  seeds.  They  are  generally  yellowish,  trans- 
lucent, and  very  hard,  though  some  have  been  described  as  friable, 
or  capable  of  being  cut  with  a  knife.  They  are  finally  laminated  con- 
centrically, and  were  found  by  Dr.  Eoberts  to  display  a  cross  with  polar- 
ized light.  The  calculi  he  describes  consisted  of  carbonate  of  lime, 
readily  detected  by  effervescence  with  hydrochloric  acid,  deposited  upon 
a  well-marked  organic  matrix  discernible  after  the  solution  of  the  eartiiy 
matter,  and  usually  mixed  with  more  or  less  phosphate.  The  influence 
of  a  colloid  fluid  in  determining  a  globular  instead  of  a  crystalline  shape 
is  well  illustrated  by  these  calculi.  There  is  reason  to  believe  that  of  all 
calculi  those  of  carbonate  of  lime  are  most  closely  dependent  in  their 
origin,  and  not  so  much  upon  urine  as  upon  pus  and  other  products  of 
disease  within  the  urinary  cavities,  and  the  prostatic  secretion  within  its 
own  channels.  As  a  urinary  formation  this  substance  is  of  exceeding 
rarity  save  as  a  secondary  deposit.^  It  has  indeed  been  doubted  whether 
carbonate  of  lime  ^  is  ever  deposited  from  the  urine  in  the  form  in  stone, 
but  it  is  at  least  certain  that  it  is  thus  thrown  down  either  by  the  urine 
itself,  or  by  pus  or  other  morbid  products  mingled  with  the  urine,  and 
so  not  only  sometimes  forms  a  part  of  comiDOund  calculi,  but  may  be  the 
chief  component  of  simple  ones.  In  compound  stones  carbonate  of  lime 
is  not  rarely  deposited  with  or  after  phosphates;  the  table  gives  five  in- 
stances in  which  it  has  thus  formed  a  component  of  renal  calculi.  As  a 
concretion  within  the  kidney,  independently  of  any  preceding  calculous 
deposit,  we  have  evidence  of  its  occurrence  in  at  least  two  instances.^  For 
one  we  are  indebted  to  Mr.  "Wagstaffe,  whose  description  may  be  inserted 
as  relating  to  a  case  in  some  respects  unique. 

A  large  branching  calculus  was  found  in  the  right  kidney,  and  had 
generally  a  dark-brown  color,  though  the  portions  which  projected  into 
the  calyces  were  colorless  and  presented,  where  not  in  contact  with  other 
calculi,  a  translucent  crystalline  surface.  A  quantity  of  brown  sand  and 
several  rounded  loose  calculi  lay  in  the  calyces. 

Tliis  specimen,  though  solitary,  is  not  deficient  in  variety,  presenting, 
muUum  mparvo,  five  different  forms  of  the  calculous  deposit. 

1.  The  mass  in  the  pelvis  was  of  a  dark- brown  color  and  very  hard, 
closely  resembling  uric  acid  in  appearance. 

'  There  is  but  a  single  specimen  of  carbonate  of  lime  in  the  fine  collection  of 
urinary  calculi  at  the  College  of  Surgeons;  and  this,  though  it  was  removed  from 
the  bladder  by  lithotomy,  is  regarded  by  Mr.  Taylor,  with  apparent  justice,  as  of 
prostatic  origin,  having  escaped  probably  by  ulceration  into  the  cavity  from 
whence  it  was  removed.  The  symptoms  of  stone  in  the  bladder  had  been  pre- 
ceded by  those  of  severe  prostatic  irritation.  The  stone  contained  89  per  cent  of 
carbonate  of  lime,  the  rest  being  oxalate  and  phosphate  of  lime,  phosphate  of 
magnesia  and  ammonia,  and  animal  matter.  See  catalogue  of  the  calculi  in  the 
College  of  Surgeons,  by  T.  Taylor.     Supplement  i.  series  ix.,  li, 

^  Thudichum,  quoted  by  Ord,  Inflxience  of  colloids  upon  crystalline  form,  p.  142. 

3  Trans,  of  the  Path.  Soc.  vol.  xix.  p.  270. 


148  RENAL    CALCULI. 

2.  The  projections  in  the  calyces,  when  not  exposed  to  pressure  or 
attrition,  were  u})piirently  made  up  of  siiining  white  crystals  somewhat 
like  triple  i)hosphates. 

3.  The  small  detached  calculi  were  hard,  smooth,  and  laminated. 

4.  Some  of  the  free  ends  and  some  of  the  isolated  calculi  were  covered 
with  a  dry,  soft,  opaque-white,  pulverulent  deposit,  looking  very  much 
like  phosphate  of  lime. 

5.  The  small  calculous  grit  had  the  shape  of  little  brownish  spherules, 
very  hard  and  identical  in  appearance  Avitli  uric  acid.  These  Avere  lami- 
nated iji  structure. 

*Eacli  of  these  kinds  proved  to  consist  of  carbonate  of  lime  with  a 
very  minute  trace  of  phosphate.  They  all  evolved  gas  freely  witli  hydro- 
chloric acid,  leaving  in  the  case  of  the  laminated  spherules  an  animal 
matrix,  which  retained  the  spherical  form. 

The  specimen  was  obtained  from  the  body  of  a  man  forty-two  years  of 
age,  Avho  died  of  disease  of  the  heart  and  cirrhosis  of  the  liver.  Tliere 
was  much  anasarca.  Tiie  urine  was  slightly  albuminous  but  otherwise 
natural.  The  only  symptom  recognized  in  connection  with  the  calcu- 
lus was  an  attack  of  hsematuria,  which  occurred  rather  more  than  two 
months  before  death,  and  lasted  two  or  three  days. 

Dr.  JIaldane  found  half  a  teaspoonful  of  sandy  matter,  held  together 
by  a  liocculent  substance,  which  resembled  coagulated  blood,  in  the  pelvis 
of  the  left  kidney  of  a  man  who  had  caries  of  the  lumbar  vertebrae.  The 
particles  were  generally  of  the  size  of  grains  of  sand;  some  were  as  large 
as  hemji-seeds.  Dr.  Koberts,  Avho  reports  the  case,'  found  the  matter  to 
consist  of  an  animal  matrix,  impregnated  with  carbonate  of  lime  mixed 
with  a  little  phosphate.  A  few  gritty  particles  were  imbedded  in  the 
cones  of  the  right  kidney,  which  wore  also  found  to  consist  i)artly  of  car- 
bonate of  lime. 

We  may  infer  that  carbonate  of  lime  is  precipitated  from  ammoniacal 
urine  by  the  carbonate  of  ammonui  v/hich  it  contains,  in  company  with 
the  phospliates. 

When  the  carbonate  occurs  alone,  as  in  the  case  which  has  been  re- 
lated, we  must  jiresume  that  the  phosphates  were  simultaneously  formed, 
but  failed  to  concrete.  Possibly  the  capacity  Avhich  carbonate  of  lime 
has  of  aggregating  into  spherules  may  exjilain  its  separation  and  reten- 
tion apart  from  other  deposits.  When  carbonate  of  lime  forms  a  compo- 
nent of  compound  renal  calculi,  it  almost  invariably  occurs  subsequently 
to  or  in  company  with  earthy  or  triple  phosphate.  In  four  cases  out  of 
five  comprised  in  the  table  it  occurred  with  or  upon  jihosphate  of  lime, 
probably  ensuing  from  the  development  of  ammonia  in  urine  previously 
alkaline. 

Cystine  and  the  Cystine  Diathesis. 

Cystine  (CgH^NSO^)  is  one  of  the  rarer  of  urinary  concretions.  It 
was  called  cystic  oxide  by  its  discover.  Dr.  Wollaston,  because  the  earlier 
specimens  were  from  the  bladder,  though  it  is  perhaps  more  often  found 
in  the  cavity  of  the  kidney.  It  is  remarkable  for  the  quantity  of  sulphur 
it  contains,  no  less  than  25.5  per  cent,  or  more  than  a  quarter  of  its 
weight.  This  substance  generally  occurs  alone,  though  it  occasionally 
happens  that  a  cystine  calculus  becomes  coated  with  phosphates,  and  in- 
stances have  been  known  in  which  cystine  has  been  deposited  upon  uric 

'  Roberts's  Urinary  and  Renal  Diseases,  3d  edit.  p.  286. 


RENAL    CALCULI.  149 

acid  or  variously  associated   in  calculi  witli  phosphates,  oxalates,  and 
urates. 

Calculi  of  this  substance  appear  generally,  or  at  least  frequently,  to 
originate  in  the  kidneys.  They  not  unfrequently  traverse  the  ureter  and 
escape  by  the  urethra  in  a  lenticular  or  pisiform  character.  In  the  blad- 
der they  sometimes  attain  a  considerable  size,  seldom,  however,  reaching 
the  weight  of  two  ounces.  The  largest  known  specimen  is  in  the  Museum 
of  University  College;  it  weighed,  when  entire,  850  grains.  It  was  ex- 
tracted from  the  bladder  by  Listen.  The  most  numerous  were  those, 
nineteen  in  number,  which  were  removed  by  Mr.  Christopher  Heath,  by 
lithotomy,  three  from  the  bladder,  the  rest  from  the  prostate.' 

Cystine  is  comparatively  soft,  forming  stones  which  are  favorable  ob- 
jects for  the  lithotrite.  Tliey  have  a  waxy,  semi-transparent  aspect  and 
crystalline  structure.  It  has,  when  fresh,  a  decidedly  yellow  color, 
which  on  exposure  changes  to  a  delicate  leek-green.  Cystine  is  insoluble 
in  water,  alcohol,  and  ether;  it  is  dissolved  by  the  stronger  acids,  by  the 
caustic  alkalies,  and  by  tlie  bicarbonates  of  potash  and  soda.  It  can 
generally  be  recognized  by  dissolving  a  })ortion  in  ammonia  and  allowing 
the  solution  to  evaporate,  whereupon  the  characteristic  hexagonal  crys- 
tals Avill  be  obtained;^  when  heated,  cystine  decomposes  with  a  peculiar 
and  disgusting  odor. 

The  circumstances  Avhich  lead  to  the  formation  of  cystine  are  matters 
of  conjecture.  It  is  secreted  as  such  by  the  kidneys  in  consequence,  as 
we  must  suppose,  of  the  superabundance  of  its  elements  in  the  blood. 
The  sulphur  may  theoretically  be  attributed  to  the  deficient  oxidation  of 
albumin.  It  has  been  shown  that  healthy  urine  contains  sulphur  not 
only  as  sulphuric  acid,  but  also  in  an  unoxidized  state,  and  it  is  conceiv- 
able that  an  increase  of  sulphur  in  this  state,  owing  to  excess  of  sulphur 
or  lack  of  oxygen,  may  result  in  the  formation  of  cystine.  Dr.  Bence 
Jones  thus  explains  the  formation  of  cystine,  as  of  much  else,  to  depend 
on  deficient  oxidation,  and  from  the  composition  of  the  substance,  as  well 
from  what  little  is  known  of  the  antecedents  of  those  in  whom  it  has 
been  developed,  there  is  some  warrant  for  such  a  theory. 

Dr.  Prout  mentions  eight  cases  of  which  the  antecedents  were  ascer- 
tained in  which  cystine  as  calculi  or  crystals  was  found.  One  of  the 
subjects  was  described  as  bilious  or  dyspeptic,  one  as  leading  a  sedentary 
life,  another  as  a  stout  and  corpulent  woman,  a  fourth  as  having  indulged 
freely  in  eating,  as  well  as  in  spirits  and  wine.  These  facts,  however, 
may  be  looked  at  from  a  different  point  of  view.  Many  circumstances 
point  to  the  liver  as  the  source  of  cystine,  and  to  cystinuriaas  but  a  sign 
of  hepatic  derangement.  Cystine,  as  pointed  out  by  Dr.  Roberts,  is 
closely  similar  to  taurin  in  composition.  Cystine  has  been  found  in  the 
liver  of  typhoid  patients.  In  some  cases  cystinuria  has  been  associated 
with  jaundice  or  other  evidence  of  hepatic  disturbance. 

In  the  year  187G  I  saw,  with  my  friend  Dr.  Glover,  of  Highbury,  a 
member  of  our  own  profession,  who  had  habitually  passed  cystine  crys- 
tals with  the  urine  since  the  year  1856,  and  at  intervals  since  this  date 
three  calculi  of  the  same  substance,  with  symptoms  of  their  having  come 
from  the  kidney. 

The  patient,  when  I  saw  him,  had  extreme  ascites,  with  evidence  of 

'  Path.  Trans,  vol.  xxvii.  p.  306;  also  vol.  xxix.  p.  154. 

^  It  is  to  be  observed  that  uric  acid  will  sometimes,  though  rarely,  take  the 
shape  of  hexagonal  plates,  which  in  form  and  appearance  are  not  to  be  distin- 
guished from  cystine. 


150  RENAL   CALCULI. 

obstruction  of  the  portal  vein,  which  his  eventual  recovery  indicated  as 
thrombotic.  He  had  established  no  claim  to  hepatic  disease  by  his  hab- 
its, which  had  always  been  active  and  abstemious,  but  liis  dark  hair  and 
sallow  comiilexion  pointed  to  what  is  called  a  bilious  temperament;  and 
disturbance,  connected  apparently  with  hepatic  inaction,  was  frequent 
with  him.  A  second  attack,  apparently  of  portal  thrombosis,  more  se- 
vere than  the  first,  and  attended  Avith  hsematemesis  profuse  enough  to 
endanger  life,  occurred  during  the  year  1880.  During  convalescence 
from  this  at  Lowestoft,  the  cystine  was  observed  to  be  unusually  abun- 
dant. It  was  noted  that  bile  was  almost  absent  from  the  stools,  the  previ- 
ous inactivity  of  the  liver  having  been  aggravated  apparently  by  the  influ- 
ence of  the  locality.  No  hereditary  proclivity  has  been  traced  in  this 
case;  there  are  several  sons  and  daughters,  in  none  of  whom  has  cystin- 
uria  been  discovered. 

The  patient  from  whom  the  cystine  calculi  were  removed  by  Mr. 
Christopher  Heath  was  found  after  death  to  have  a  liver  which  is  de- 
scribed as  "amyloid  and  somewhat  enlarged.'' 

It  must  be  allowed,  however,  that  the  clinical  associations  of  cystin- 
uria  are  too  various  to  warrant  any  conclusive  deduction  on  this  head. 
Cystine  has  been  passed  with  the  urine  without  any  other  noticeable  dis- 
turbance of  health,  by  children  frequently,  and  in  later  life  for  years 
together.  It  has  been  passed  by  scrofulous,  tuberculous,  and  chlorotic 
persons,  as  well  as  by  many  who  jiresent  none  of  these  conditions;  per- 
sons haJjitually  exposed  to  wet  and  cold,  like  a  sexton,  operated  on  by 
Mr.  Southam,'  of  Manchester,  have  been  the  subjects  of  cystine  concre- 
tions, and  in  one  instance  calculi  of  this  kind  were  found  in  the  kidneys 
of  a  lunatic*  who  was  intemperate,  while  in  many  cases  no  pathological 
association  has  been  noticed  or  recorded. 

The  most  striking  clinical  peculiarity  of  cystine  is  its  tendency  to  run 
in  families.  Many  cases  have  been  recorded  in  which  brothers,  or 
brothers  and  sisters,  have  passed  or  concreted  it,  others  in  which  a  cys- 
tine calculus  has  descended  as  an  heirloom  from  father  to  son.  Dr.  Mar- 
cet  mentions  two  brothers  who  died,  one  at  the  age  of  thirty,  the  other 
between  thirty  and  forty,  Avith  symptoms  of  renal  calculus,  cystine 
stones  being  found  in  the  kidneys  of  both.  A  calculus  was  extracted 
from  the  urethra  of  a  third  brother,  but  its  nature  was  not  ascertained. 
Both  Lenoir  and  Civiale  extracted  cystine  calculi  from  the  bladders  of  two 
brothers.'  A  boy  was  cut  for  stone  by  Mr.  Teale,  of  Leeds,  and  a  cystine 
calculus  removed.  Two  of  his  brothers  passed  crystals  of  cystine  with 
iJie  urine.^ 

According  to  Poland,  out  of  twenty-two  collected  cases  of  cystine  cal- 
ouli,  ten  occurred  in  four  families,  while  in  three  cases  the  subjects  of 
the  complaint  Avere  brothers.  Golding  Bird  alludes  to  an  instance  in 
which  cystine  was  found  in  the  urine  in  three  successive  generations. 

As  to  the  treatment  of  the  cystine  diathesis  we  have,  from  the  rarity 
of  the  condition,  little  experience.  Dr.  Prout  advises  the  avoidance  of 
indigestible  food  and  the  use  of  nitro-muriatic  acid;  Dr.  Bence  Jones 
urges  measures  of  oxidation.     In  deference  alike  to  every  view   we  may 

'  Brit.  Med.  Journ.  Dec.  23d,  1876. 
'  Dr.  Risdon  Bennett,  Path.  Trans,  vol.  iii.  p.  383. 
^  Roberts's  Urinary  and  Renal  Diseases,  p.  219. 

*  Related  by  Dr.  Beale.  Kidney  Diseases,  Urinary  Deposits,  and  Calculous 
Disorders,  3d  edition,  p.  386. 


RENAL    CALCULI.  151 

commend  abstinence  and  exercise,  while  if  there  be  apparent  need,  med- 
icines of  cholagogue  repute  may  be  employed. 

Indigo. 

On  the  observation  of  Dr.  Ord'  indigo  must  be  added  to  the  list  of 
substances  Avhich  may  concrete  in  the  kidney.  The  left  kidney  of  a 
woman  of  middle  age  had  been  destroyed  by  a  small,  round-celled  sar- 
coma, and  reduced  by  obstruction  of  the  ureter  to  a  closed  cyst,  which 
contained  a  branched  earthy  calculus  of  which  nothing  further  is  related. 
The  right  kidney  was  hypertrophied  and  somewhat  hypergeniic,  but 
healthy  in  structure.  In  its  pelvis  was  found  a  calculus  of  the  size  and 
shape  of  a  fruit  lozenge  and  the  weight  of  forty  grains.  This  was  partly  of 
a  dark-brown  and  partly  of  a  blue-black  color,  granular  and  without  polish. 
It  made  a  blue-black  mark  on  paper,  and  gave  chemical  reactions  charac- 
teristic of  indigo,  of  which  its  bulk  consisted.  Associated  with  this  was 
a  small  quantity  of  phosphate  of  lime;  and  the  brown  part  of  the  stone 
displayed  crystals  of  hasmin. 

The  existence  of  indigo  in  the  urine  has  often  attracted  notice;  its 
concretion  never  before.  Little  is  positively  known  with  regard  to  the 
source  of  indigo  in  the  urine,  except  that  a  substance  indistinguishable 
from  it  appears  in  this  secretion  after  the  ingestion  of  creasote  or  carbolic 
acid,  the  former  of  Avhich,  as  Dr.  Ord  informs  us,  had  been  taken  by  the 
patient  from  whom  the  calculus  was  obtained.  Apart  from  this  mode 
of  introduction,  circumstances  of  two  kinds  are  to  be  recognized  as  often 
preceding  the  discharge  of  this  pigment,  or  a  substance  easily  convertible 
into  it,  with  the  urine — the  confinement  of  pus  within  the  body,  and  dis- 
ease of  the  intestines.  I  displayed  at  the  Pathological  Society'^  some 
urine  which  contained  an  amount  of  indigo  I  believe  unexampled,  which 
had  been  passed  by  a  young  woman  in  whose  abdomen  was  found  a  cir- 
cumscribed abscess,  ■which  held  at  least  two  quarts,  in  connection  with 
an  ulcer  of  the  stomach.  Dr.  Ord  points  out  that  some  such  retention 
with  consequent  absorption  may  have  occurred  as  the  cause  of  the  indigo 
calculus,  since  the  kidney,  in  which  it  was  not,  had  been  destroyed  while 
its  exit  was  closed.  That  jdus  is  occasionally  associated  with  pigment  has 
been  testified  by  the  green  and  blue  colors  known  to  have  been  i^resented 
by  this  secretion.  With  regard  to  intestinal  disturbance  as  preceding 
the  escape  of  indigo  and  allied  substances  with  tlie  urine,  we  have  the 
examples  of  Asiatic  cholera  and  obstruction  of  the  bowel  of  various  kinds, 
the  result  being  due,  as  is  suggested,^  to  the  non-escape  and  consequent 
absorption  and  excretion  of  indol,  a  product  of  pancreatic  digestion  which 
has  a  near  chemical  relation  to  indigo. 

Fibrinous  and  Blood  Calculi. 

Concretions  to  which  these  names  have  been  applied  may  receive  a 
passing  notice,  more  especially  as  they  are  sometimes  very  hard,  and 
passed  with  as  much  pain  and  difficulty  as  if  of  stony  substance.  The 
fibrinous  calculus  of  Marcet  has  been  described  as  of  much  the  color  and 

'  Ord,  On  the  influence  of  colloids  upon  crystalline  form,  p.  144;  also  Path. 
Trans,  vol.  xxix.  p.  155. 

^  Path.  Trans,  vol.  xvi.  p.  181. 

^Thudichum,  On  the  Urine,  2d  edit.  p.  179;  also  Ord,  loc.  cit.  p.  149. 


152  KENAL    CALCULI. 

consistence  of  bees'  wax,  and  as  presenting  the  reactions  of  fibrin.  Other 
concretions  have  been  more  distinctly  sanguineous,  and  have  given  evi- 
dence in  color  and  structure  of  the  presence  of  blood-corpuscles.  Such 
an  instance,  which  was  observed  at  the  Consumption  Hospital  by  Dr. 
Scott  Alison,  is  recorded  and  figured  by  Dr.  Bcale.'  The  kidney  was 
reduced  to  a  thin  sac,  which  weighed  but  one  and  a  half  ounce.  The 
infundibulum  and  pelvis  were  stuffed  Avith  hard  bodies,  most  of  which 
were  of  a  coal-black  color,  but  some  whitish-gray.  The  black  calculi, 
which  were  chiefly  within  the  pelvis,  were  about  six  in  number,  and 
ranged  from  the  size  of  a  coriander  seed  to  that  of  a  horse-bean.  They 
were  hard  but  friable;  they  were  soluble  in  ammonia,  and  displayed  forms 
which  Avere  thought  to  be  the  remains  of  blood-corpuscles.  The  gray 
calculi  which  were  in  the  infundibulum  were  apparently  phosjihatic.  It 
is  probable  that  the  changes  originated  in  these  or  other  calculi  of  one  of 
the  ordinary  types  by  which  the  ureter  was  obstructed,  the  kidney  trans- 
formed, and  hemorrhage  produced,  the  blood  being  retained  within  the 
closed  cavity  to  undergo  further  changes. 

It  has  been  supposed  that  the  so-called  fibrinous  calculi  were  the  pro- 
duct of  an  albuminous  exudation  from  the  kidney,  but  tliis  is  hypotheti- 
cal; it  is  more  consistent  with  experience  to  regard  these  as  blood-clots 
modified  by  time  and  maceration.  Vermiform  coagula  from  the  ureter 
are  well-known,  as  also  are  the  lumps  of  cancer'  which  are  sometimes  ex- 
pelled from  the  bladder  in  disease  belonging  to  this  organ;  these  cannot 
be  called  calculi,  though  they  may  possibly  become  encrusted  so  as  to. 
give  rise  to  them. 

Urostealith. 

A  fatty  or  saponaceous  substance,  to  which  this  name  has  beeir 
given,  has  been  met  with  as  forming  the  chief  bulk,  or  the  central  por- 
tion only,  of  concretions  which  have  been  found  in  the  bladder  or  passed 
from  it.  It  does  not  appear  ever  to  have  been  seen  in  the  kidney,  and 
therefore  does  not  fairly  come  within  the  scope  of  this  work.  The  best- 
known  and  earliest  described  specimens  are  the  two  in  the  College  of  Sur- 
geons,^ in  each  of  which  a  lump  of  fatty  or  soapy  material,  consisting  of 
oleate  and  margarate  of  lime,  has  become  involved  with  concentric  lay- 
ers of  phosphates,  so  as  to  present  the  exterior  of  a  common  vesical  cal- 
culus. The  fatty  centre  in  one  case  presents  a  section  as  large  as  a  six- 
pence, the  other  is  not  much  smaller.  There  is  no  reason  to  doubt  the 
explanation  provided  by  Mr.  Taylor,  that  these  concretions  have  been 
produced  by  the  injection  of  soap  into  the  bladder  for  the  cure  of  stone 
or  some  affection  mistaken  for  it.  The  soap  in  this  view  has  been  de- 
composed by  the  urine,  the  alkali  forming  soluble  salts  with  the  urinary 
acids,  and  the  fat  concreting  with  the  urinary  lime.  Nearly  resembling 
these  "  soap-stones,"  and  possibly  of  a  similar  origin,  though,  as  in  the 
Hunterian  case,  we  have  no  history  to  bear  out  the  supposition,  were 
some  concretions  which  were  passed  by  the  urethra,  described  by  Heller 
in  the  year  1845,  and  dignified  with  the  name  Urostealith.  A  peculiar- 
ity of  these  fatty  bodies  w:is  a  resinous  or  aromatic  odor  emitted  on  com- 
bustion.    Later,  some  apparently  similar  calculi  were  described  by  Dr. 

'  Kidney  Diseases,  3d  edit.  p.  409. 

'See  case  which  I  contributed  to  Path.  Trans,  vol.  xx.  p.  233. 

^  Catalogue  of  Calculi,  part  i.  published  1842,  p.  129,  plate  xi. 


EENAL    CALCULI.  153^ 

Moore.'  Two  passed  from  the  bladder  were  of  a  brown  color,  and  con- 
sisted of  fatty  matter  in  combination  witb.  lime.  Of  two  removed  from 
the  body  of  the  same  patient,  presumably  from  tbe  bladder,  one  was  a 
common  phosphatic  stone,  the  other,  which  was  as  large  as  a  hen's  egg, 
consisted  of  phosphate  of  lime  and  fusible  calculus  externally,  while 
within  was  a  cavity  containing,  but  not  filled  by,  a  quantity  of  the  same 
dark  brown  fatty  substance  which  was  found  in  the  concretions  which 
had  before  been  passed. 

We  know  that  fat  is  passed  abundantly  with  the  urine  when  chyle 
becomes  mixed  with  it,  but  there  must  be  considerable  doubt  as  to 
whether  oil  or  fat  in  a  separate  form  and  tangible  quantity  is  ever  a  pro- 
duct of  renal  secretion.  A  few  instances  have  been  reported  in  which 
oil  or  fat  has  been  found  in  the  urine,  and  believed  to  have  been  secreted 
with  it;  it  hiis  even  been  sui)})osed  that  a  dose  of  castor  oil  has  been 
chiefly  eliminated  by  the  kidneys;  further  observations  are  needed  before 
the  intervention  of  error,  accident,  or  fraud  can  be  looked  upon  as  alto- 
gether outside  the  question. 

Differential  Diagnosis  of  Eenal  Calculi. 

It  may  be  convenient  to  condense  into  a  few  sentences  the  chief  con- 
siderations by  which  we  can  ascertain,  or  with  probability  conjecture, 
the  nature  of  a  calculus  lodged  in  the  kidney. 

Should  calculi  have  been  previously  voided  and  preserved  they  will 
give  the  most  trustworthy  information.  It  may,  as  a  general  rule,  be 
inferred  that  stones  left  behind  or  subsequently  formed  are  of  the  same 
nature  as  those  which  have  escaped,  or  differ  from  them  only  in  the  ac- 
quirement of  a  phosphatic  crust. 

Information  will  be  given  by  the  habitual  reaction  of  the  urine.  Uric 
acid  and  oxalate  of  lime  are  deposited  by  acid  urine,  j)hosphate  of  lime  by 
urine  alkaline  from  fixed  alkali,  mixed  or  triple  phosphate  by  ammoniacal 
urine . 

If  the  urine  be  constantly  acid  and  free  from  pus  or  mucus  it  may  be 
presumed  that  a  renal  calculus  consists  either  of  uric  acid  or  oxalate  of 
lime,  or  of  both  together.  It  must  be  borne  in  mind  that  the  vast  ma- 
jority of  renal  calculi  consist  either  solely  or  centrally  of  one  of  these 
substances. 

Crystals  of  uric  acid  or  oxalate  of  lime,  if  numerous,  and  particularly 
if  they  be  present  in  the  urine  when  passed,  will  furnish  a  presumption 
that  if  there  be  precipitation  in  the  kidney  it  will  be  of  the  same  kind. 
As  between  these  two  deposits,  there  will  be  an  inference  in  favor  of  oxa- 
late of  lime  if  the  urine  abound  in  earthy  salts,  or,  in  other  words,  give  a 
large  precipitate  with  liquor  potassee.  Uric  acid  will  be  pointed  to 
should  the  patient  be  gouty,  should  the  symptoms  have  originated  in 
early  childhood,  or  have  dated  from  an  attack  of  scarlatinal  nephritis. 

Should  the  urine  exhibit  oxalate  of  lime,  the  infei'cnce  that  the  cal- 
culus is  of  this  nature  will  be  strengthened  should  the  patient  be  j)allid, 
dyspeptic,  and  of  a  nervous  temperament. 

A  persistently  alkaline  state  of  urine  will  lead  to  the  inference  that 
the  stone,  whatever  be  its  centre,  is  encrusted  with  phosphates,  which, 
should  the  urine  be  ammoniacal,  will  be  of  the  mixed  variety.  The 
mixed  phosphates  being  extremely  common,  and  the  pure  phosphate  of 

'  Dublin  Quart.  Journ.  of  Med.  Science,  vol.  xvii.  May,  1854,  p.  473. 
'  Beale,  Kidney- Diseases,  3d  edit.  p.  315. 


154  RENAL  CALCULI. 

lime  extremely  rare,  it  may  generally  be  reckoned  that  should  circum- 
stances indicate  a  phospliatic  calculus  in  the  kidney  it  is  of  the  former 
kind;  should  much  pus  or  mucus  be  passed  phosphatic  dejjosition  may 
sometimes  be  inferred,  even  though  the  urine  remain  acid.  It  may  hap- 
})en  that  a  stone  in  the  pelvis  of  one  kidney  may  cause  the  urine  to  be 
alkaline  in  that  cavity  and  phosphates  to  be  there  deposited,  while  the 
acidity  of  the  secretion  is  restored  in  the  bladder  by  admixture  with  the 
healthy  product  of  the  unaffected  gland. 

Cystine,  from  its  rarity,  need  not  be  suspected  unless  the  characteris- 
tic hexagons  are  found  in  the  urine.  Should  these  concur  with  the  symp- 
toms of  renal  calculus  there  will  be  a  considerable  probability  that  the 
stone  will  be  of  unmixed  cystine. 

Urates  s(!ldom  occur  alone.  Xanthine  and  carbonate  of  lime,  may, 
from  their  rarity,  be  omitted  from  diagnostic  consideration.  Unites  and 
xanthine  occur  under  similar  circumstances  to  uric  acid;  carbonate  of 
lime  under  circumstances  similar  to  those  which  point  to  the  mixed 
phosphates. 


CHAPTER  XII. 

PATHOLOGICAL    CONSEQUENCES,    CLINICAL   RELATIONS, 
AND   SYMPTOMS   OF   RENAL   CALCULI   IN   GENERAL. 

Pathological  Consequences. 

When"  calculi  lie  in  the  kidney,  they  usually  rest  in  the  expanded 
•commencement  of  the  ureter,  or  cling  to  the  calyces;  very  rarely  they 
are  embedded  or  encysted  in  the  renal  substance.'  When  lying  in  the 
pelvis  they  are  apt  to  obstruct  the  outlet,  and  cause  more  or  less  hin- 
drance to  the  exit  of  urine.  If  the  stone  is  of  suitable  size  and  softness, 
as  happens  especially  with  uric  acid,  it  may  be  worn  by  the  friction  of 
the  mucous  membrane  to  fit  the  origin  of  the  ureter  with  water-tight 
accuracy.  In  other  circumstances,  notably  with  hard  mulberry  calculi, 
the  concretion  is  not  exactly  adapted  to  the  outlet,  and  instead  of  form- 
ing a  prohibition  to  the  escape  of  urine,  scarcely  interposes  a  difficalty. 
Considering  the  incomplete  closure  first,  this  results  in  a  gradual  dilata- 
tion of  the  mucous  cavity  of  the  kidney  with  commensurate  atrophy 
of  the  secreting  structure.  This  sometimes  is,  and  sometimes  is  not, 
accompanied  by  pyelitis.  Tlie  pelvic  mucous  membrane  takes  on  in- 
flammatory action  less  readily  than  the  vesical,  whence  urine  retained 
in  the  pelvic  cavity,  less  largely  intermixed  with  mucous  secretion,  has 
not  the  same  proneness  to  putrefactive  change  as  when  in  the  bladder. 
Hence  it  may  come  to  pass  that  simple  dilatation,  with  corresponding 
attenuation  and  atrophy  of  the  kidney,  may  be  the  only  pathological 
results  of  a  renal  stone. 

The  kidney  is  sometimes  reduced  to  a  mere  husk,  in  which  a  stone  is 
encased.  This  process  is  usually  connected  with  pyelitis,  as  explained  in 
connection  with  the  origin  of  phosphatic  calculi.  The  kidney  may  be 
dilated  as  the  result  of  stone  to  an  extent  which  varies  from  a  trifling 
increase  in  the  size  of  the  pelvis  to  such  an  expansion  that  the  organ  may 
occupy  the  greater  part  of  the  abdominal  cavity.  The  extreme  extension 
does  not  take  place  unless  the  obstruction  is  so  nearly  impassable  as  only 
to  open  at  times  and  under  ])ressare.  The  organ  under  these  circum- 
stances becomes  transformed  into  a  multilocular  cyst,  which  retains  lit- 
tle of  the  kidney  save  its  fibrous  tissue  and  something  of  its  shape.  The 
pelvis  gradually  stretches,  and  consentaneously  atrophy  of  the  secreting 

'  In  the  museum  of  Guy's  Hospital,  there  is  a  kidney  the  cortical  part  of 
which  contains  a  cyst  the  size  of  a  hazelnut,  in  which  are  some  small  calculi. 
The  cyst  has  a  narrow  communication  with  the  pelvis,  and  has  probably  been 
formed  by  an  obstruction  in  the  straight  tubes  and  accumulation  behind. 


156 


PATHOLOGICAL    RELATIONS    OF    RENAL    CALCULI. 


structure  takes  place.  Where  the  pyramids  terminate  in  the  mammary 
processes,  the  tubular  structure  is  in  immediate  contacc  with  the  accu- 
mulating fluid.     To  its  steady  pressure   their  soft  structure  gradually 


Kidney,  which  is  reduced  to  a  mere  shell,  occupied  br  enormous  calculous  masses  of  the 
mixed  phosphates.  The  patient  was  not  known  ever  to  have  had  renal  symptoms  (From  a 
preparation  in  St.  George's  Hospital.)    Case  related  by  Mr.  Holmes,  Path.  Trans,  vol.  x. 

yields,  so  that  each  pyramid  is  first  flattened  at  its  point,  then  encroached 


PATHOLOGICAL  RELATIONS  OF  RENAL  CALCULI.  157 

upon  more  and  more  until,  partly  from  atrophy  and  partly  from  dis- 
placement, the  position  of  each  cone  is  occupied  by  a  deep  inlet  from  the 
pelvis.  This  inlet  widens  and  deepens  at  the  expense,  first  of  the  me- 
dullary, then  of  the  cortical  structure,  until  at  last  it  reaches  the  cap- 
sule, which  comes  to  form  its  outer  boundary,  while  on  each  side  it 
meets  with  cavities  similarly  formed,  and  approaches  them  more  and 
more  closely  until  only  condensed  fibrous  tissue  keeps  them  apart.  The 
kidney  thus  comes  to  consist  of  a  central  cavity  corresponding  to  thejiel- 
vis,  into  which  open  a  number  of  chambers  divided  by  fibrous  septa.  In 
this  it  may  not  be  jiossible,  even  with  the  microscope,  to  find  any  tubes 
left,  but  such  a  complete  and  total  destruction  of  the  secreting  structure 
is  rare  (see  woodcuts  at  pages  99  and  100),  for  in  cases  where  no  kid- 
ney-tissue has  been  evident  to  sight,  it  has  been  found  that  the  contained 
fluid  has  still  possessed  urinous  qualities.  It  commonly  happens  that 
thin  isolated  patches  of  brown  tissue,  which  are  remnants  of  glandular 
structure,  can  be  seen  in  the  walls. 

By  the  time  that  extreme  dilatation  is  reached  it  commonly  happens 
that  more  or  less  suppurative  inflammation  has  occurred  in  the  lining 
membrane,  and  the  urinous  contents  have  become  mixed  with  pus  or 
muco-purulent  matter.  Colloid  matter  also  has  been  known  to  form  in 
the  cavity.  I  have  already  referred  to  a  cyst,^  nearly  a  yard  in  circum- 
ference, which  consisted  of  a  kidney,  dilated  and  partitioned  as  the  re- 
sult of  calculous  obstruction,  which  had  become  thus  occupied.  The 
dilatation  of  the  kidney  from  calculus  takes  place  gradually  and  pain- 
lessly, and  when  unaccompanied  by  any  discharge  of  pus  or  by  disease 
in  the  other  kidney  almost  harmlessly.  As  one  kidney  is  destroyed  the 
other  undertakes  a  compensating  hypertrophy,  and  maintains  the  func- 
tion. In  slight  cases  the  condition  of  the  organ  often  escapes  notice 
until  after  death.  When  the  dilatation  is  great  an  obvious  fluctuating 
tumor  is  found,  the  characters  of  which,  especially  if  they  be  corrobo- 
rated by  a  history  of  calculus,  may  suffice  in  a  male  subject  to  point  to 
the  nature  of  the  case.  In  the  female  it  may  require  some  care  to  dis- 
tinguish a  renal  from  an  ovarian  cyst.  Further  details  relating  to  the 
diagnosis  of  renal  cysts  are  to  be  found  elsewhere  (p.  42). 

Clinical  Eelations  akd  General   Symptoms  of  Kenal  Calculi. 

Eenal  calculi  originate  sometimes  in  the  tubes,  more  often  in  the 
pelvis  of  the  kidney.  Uric  acid,  the  urates,  oxalate  and  phosphate  of 
lime,  have  been  recognized  in  the  tubes  by  the  microscope.  They  never 
attain  a  considerable  size  in  this  situation,  but  reach  the  pelvis  as  sand 
or  grit,  thence  to  escape  or  there  to  grow.  In  the  pelvis  calculi  vary 
widely  iu  number,  shape,  physical  characters,  and  size.  The  pelvis  may 
contain  a  single  stone,  two,  or  more,  up  to  a  multitude  which  may  be 
reckoned  by  hundreds.  In  size  tlie  concretions  range  from  the  miiuit- 
est  aggregation  of  crystals  or  smallest  laminated  spherule,  up  to  a  mass 
of  stone  weighing  nearly  a  pound.  In  shape  they  have  generally,  if 
small,  more  or  less  of  a  spherical  or  ovoid  shape,  or  retain  a  crystalline 
outline;  if  large,  they  are  generally  moulded  upon  the  pelvis,  sometimes 
adapting  themselves  with  deadly  accuracy  to  the  outlet  of  the  infundib- 
ulum.     The  particular  characters  of  each  variety  of  calculus  have  been 

'  See  paf^e  55. 


158  TATHOLOGICAL    RELATIONS    OF    REXAL    CALCULI. 

severally  detailed.  It  only  remains  here  to  allude  to  such  general  con- 
siderations as  are  of  imjiortance  clinically. 

One  kidney  or  both  may  be  affected.  The  dei^osition  of  uric  acid, 
oxalate  of  lime,  and  cystine,  arising  as  it  does  from  a  state  of  blood,  is 
apt,  with  perilous  consent,  to  occur  in  both  kidneys  simultaneously  or  in 
succession.  Phosphates,  springing  from  local  causes,  are  less  often  dis- 
posed with  bilateral  symmetry.  Both  kidneys  are  affected  far  less  often 
than  one  only;  where  one  only  is  affected  the  right  has  a  slight  j^re-emi- 
nence. 

Of  fifty-nine  cases  in  which  renal  calculi  were  found  after  death  at 
St.  George's  Hospital,  both  kidneys  were  thus  occupied  in  eleven  cases, 
one  only  in  forty-eight.  The  stone  was  on  the  right  side  in  twenty-five 
cases,  on  the  left  in  twenty-three. 

Males,  according  to  the  same  showing,  are  more  subject  than  females 
to  renal  calculi.  Of  sixty  cases  thirty-six  belonged  to  the  male,  twenty- 
four  to  the  female  sex.  This  preponderance  may  be  attributed  to  the 
greater  addiction  of  males  to  excess  and  their  greater  liability  to  gout 
and  the  formation  of  uric  acid. 

With  regard  to  the  age  at  which  renal  calculus  presents  itself,  I  may 
refer  first  to  that  at  which  it  proves  fatal;  and  for  this  purpose  appeal  to 
the  sixty  cases  already  mentioned  which,  as  representing  nearly  forty 
years'  experience  of  a  general  hospital,  may  be  taken  as  demonstrative  in. 
many  respects  of  the  distribution  and  issues  of  the  formation  in  question. 
In  forty  of  the  sixty  cases  in  which  renal  stone  was  found,  death  was  due 
to  causes  independent  of  it;  in  twenty  it  was  produced  more  or  less  di- 

Age  at  death  with  and  from  I'enal  calculus.     From  Post-mortem  Books 
of  St.  George's  Hosjntal. 


Age  at  Death. 


0  to  9  years. 
10  to  19  years. 
20  to  29  years. 
30  to  39  years. 
40  to  49  years. 
50  to  59  years . 
60  to  69  years 
70  to  79  years. 
80  to  89  years. 


Of   60  persons 
who  died  with 

Of    20 

of   the 

renal     calcu- 

number  who 

lus. 

died 

of  It. 

1 

0 

3 

0 

15 

7 

4 

2 

12 

5 

14 

3 

8 

1 

2 

1 

1 

1 

Of  the  patients  referred  to,  the  youngest  died  at  the  age  of  one  year,  the  oldest 
at  that  of  eighty-eight. 

rectly  by  the  stone.  Of  three  people  who  have  stone  one  will  die  of  it; 
thus  far  is  the  disease  fatal  and  no  farther.  There  appear  to  be  two 
periods  at  which  death  is  prone  to  occur:  between  twenty  and  thirty,  and 
between  forty  and  fifty.  The  earlier  date  probably  belongs  to  the  stones 
which  are  originated,  as  so  many  are,  in  infancy  or  early  childhood;  the 
latter  to  those  which  are  developed  by  the  habits  and  accidents  of  adult 
life. 

It  is  evident  that  renal  calculi  take  their  rise  more  often  before  than 


PATHOLOGICAL   RELATIONS    OF    RENAL    CALCULI.  159 

after  middle  age.  It  is  probable  that  the  uric  acid  concretions  of  the 
first  few  days  of  extra-uterine  life  often  form  their  nuclei,  while  it  has. 
been  shown  that  scarlatina  not  seldom  leads  to  a  deposition  of  the  same 
kind.  Thus  calculi  with  a  centre  of  uric  acid  may  be  often  traced  to 
infancy  or  childhood.  With  regard  to  oxalate  of  lime  it  would  seem  to 
be  more  often  deposited  after  than  before  puberty.  It  is  extremely  difficult, 
from  the  frequent  latency  of  the  disease,  to  obtain  satisfactory  clinical  evi- 
dence as  to  the  time  at  which  in  any  particular  case  it  originated;  but  it 
very  frequently  happens  that  it  can  be  traced  back  from  middle  or  ad- 
vanced age  to  childhood  or  early  life. 

Stone  in  the  kidney  varies  more  than  most  disorders  in  its  history,  its 
symptoms,  and  its  issues.  It  generally  makes  itself  known  by  pain  and 
bleeding,  but  these  symi)toms  are  not  always  present.  It  is  sometimes 
latent  and  apparently  harmless.  Occasionally  stones  of  enormous  size 
are  discovered  in  the  kidney  after  death  (see  woodcut,  page  143),  though 
no  renal  disturbance  had  been  known  to  exist  at  any  period  of  life.  In 
other  cases  a  renal  stone  produces  an  amount  and  persistence  of  suffer- 
ing which  entitles  it  to  be  regarded  as  one  of  the  most  unwelcome,  as  it 
is  one  of  the  most  tenacious,  companions  that  a  man  can  travel  withal. 
Stones  in  the  bladder  may  burst,  or  disintegrate,  and  come  away  piece- 
meal, but  it  does  not  appear  that  renal  stones  are  capable  of  this  process 
of  natural  lithotrity.* 

The  stone  may  lie  in  the  infundibulum,  which,  as  has  been  stated,  it 
may  be  moulded  to  fit,  or  one,  or  several  may  be  seen  holding  tenaciously 
to  the  calyces.  A  calculus  of  considerable  size  may  have  its  lower  part 
in  the  infundibulum,  while  the  upper  end  is  jagged  or  branched,  so  as 
to  be  adapted  to  these  points  of  discharge. 

The  symptoms  which  it  causes  depend  first  upon  the  contact  of  the 
stone  with  the  sensitive  and  irritable  mucous  membrane,  producing  pain, 
inflammation,  and  bleeding ;  secondly,  upon  the  mechanical  hindrance 
to  the  escape  of  urine,  whereby  the  kidney  becomes  variously  damaged 
by  extension  and  pressure,  and  whence,  should  both  kidneys  be  involved, 
fatal  suppression  of  urine  may  result.  Putting  aside  for  the  present  the 
consequences  of  obstruction,  we  may  consider  the  more  ordinary  symp- 
toms of  renal  calculus,  which  are  those  associated  with  irritation  and 
hemorrhage. 

Prout  describes  the  most  frequent  symptoms  produced  by  foreign 
bodies  in  the  kidney  as  being  lumbar  pain,  gastric  disturbance,  retrac- 
tion of  the  testes,  and  bloody  urine. 

The  kidney  is  not  only  a  highly  vascular  organ,  prone  to  discharge- 
blood  on  small  provocation,  but  it  is  endowed  with  extensive  nervous 
connections,  the  influence  of  which  we  see  in  many  phases  of  disturbed 
action  under  the  irritation  of  a  stone. 

So  long  as  a  stone  is  perfectly  quiet  it  may  cause  no  pain,  nor  any 
symptoms  by  which  its  presence  can  be  recognized.  Hence  it  often 
happens  that  a  very  large  calculus   tightly  embraced   by  an   atrophied 

'  See  paper,  by  Dr.  Ord,  on  the  "Spontaneous  disintegration  of  vesical  cal- 
culi," Path.  Trans,  vol.  xxxii.  p.  304. 

The  kidney  is  brought  by  the  pneumogastric  nerve  into  sympathy  with  the 
stomach,  by  the  spermatic  plexus  into  relation  with  the  course  of  the  ureter  and 
substance  of  the  testicle,  with  the  cremaster  muscle  and  skin  of  the  inside  of  the 
thigh  by  means  of  the  genito-crural  nerve,  while  the  anterior  crural  nerve  estab- 
lishes a  less  direct  communication  between  the  kidney  and  other  parts  of  the 
lower  extremity. 


160  PATHOLOGICAL  RELATIONS  OF  RENAL  CALCULI. 

kidney  is  latent ;  but  immediately  the  stone  stirs  in  the  pelvis,  or,  if 
small  enough,  when  it  enters  the  ureter,  the  extensive  sympathies  of  the 
organ  are  awakened. 

There  is  a  distinction  between  the  symptoms  produced  by  a  stone  as 
it  lies  in  the  kidney,  and  as  it  traverses  the  ureter.  Dealing  first  with 
the  symptoms  of  an  imprisoned  or  unavoidable  stone  they  are  widely 
various.  To  quote  the  words  of  Prout,  ''  the  pain  produced  by  the  pres- 
ence of  renal  concretions  differs  almost  infinitely  both  in  kind  and  de- 
gree." 

The  pain  is  generally  of  a  dull  kind,  a  sense  rather  of  weight  than 
pain,  felt  at  times  in  the  loin  of  the  affected  side,  and  possibly  more  or 
less  in  the  other,  though  one  kidney  only  is  diseased.  The  pain  some- 
times passes  along  the  course  of  the  ureter  into  the  testicle,  which  niay 
be  retracted,  swollen,  and  painful,  and  into  the  thigh,  affecting  especially 
its  inner  surface,  which  often  becomes  numb.  Sometimes  the  pain 
reaches  or  appears  only  in  the  lower  parts  of  the  limb;  a  case  is  recorded 
in  which  obstinate  pain  in  the  knee  was  found  after  death  to  have  been 
associated  with  a  renal  calculus.  I  had  a  patient  in  whom  the  chief  pain 
caused  by  a  concretion  of  this  nature  was  in  the  sole  of  the  foot,  and  an- 
other in  whom  much  of  it  was  in  this  position  :  in  the  latter  instance 
the  sensation  was  '*as  if  the  sole  were  raw  and  being  rubbed  with  scour- 
ing-])aper." 

There  is  often  some  degree  of  tenderness  over  the  affected  kidney 
either  in  the  back  or  on  deep  pressure  of  the  abdomen  a  little  on  one 
side  of  the  umbilicus. 

The  pain  is  generally  inconstant;  often  absent  or  trifling  during  bod- 
ily quiescence,  aggravated  by  movements,  especially  such  as  are  jerking 
or  tremulous.  Of  all  modes  of  locomotion  walking  is  the  best  borne.  It 
is  sometimes  found  that  when  the  pain  is  of  the  paroxysmal  neuralgic 
type,  pedestrian  exercise,  with  its  concomitants  of  fresh  air  and  change 
of  scene,  lessens  the  frequency  and  severity  of  the  attacks. 

Riding  on  horseback  is  more  constantly  injurious,  as  also  are  the  jolt- 
ing or  vibratory  movements  of  a  carriage. 

With  regard  to  the  sensations  produced  by  a  stone  in  the  kidney, 
Howship  observes  that  even  a  small  calculus  will  in  some  cases  excite  a 
a  distinct  impression  as  to  its  existence  in  the  patient's  mind.  In  one 
instance  he  found  a  small  stone  not  larger  than  a  pea  in  the  kidney,  with 
scarcely  any  evidence  of  consequent  irritation,  where  t  e  patient  had  for 
two  years  been  conscious  of  a  stone  in  that  situation.  He  alludes  to  an- 
other patient  who  was  made  aware  of  the  i^resence  of  stones  in  her  kid- 
ney by  their  grating  together  on  movement  of  the  body.' 

Recently  my  colleague,  Mr.  Pick,  ascertained  the  existence  of  stones 
in  the  kidney  by  making  them  grate  upon  each  other  i)erceptibly  to  him- 
self by  pressure  of  the  hands  before  and  behind. 

Prout  observes,^  with  general  truth,  that  of  renal  concretions  lithic 
acid  produces  the  least  pain,  what  there  is  being  dull,  oppressive,  and 
connected  with  a  sense  of  weight:  oxalate  of  lime  causes  jain  of  a  more 
acute  kind,  and  that  often  referred  to  a  particular  spot  over  the  region 
of  the  kidney,  and  sometimes  discursive,  shooting  in  the  direction  of  the 
ureter,  epigastrium,  or  shoulder.     Phosphates  he  has  found  to  be  attended 


'  Howship,  On  the  Urinary  Organs,  p.  105. 
"  On  Stomach  and  Renal  Diseases,  p.  298. 


PATHOLOGICAL  RELATIONS  OF  EKNAL  CALCULI.  161 

Avith  great  suffering — almost  unremitting,  though  paroxysmally  aggra- 
vated. 

These  distinctions  correspond  with  much  of  our  experience.  Severe 
neuralgic  anguish  is  undoubtedly  most  apt  to  occur  with  long-standing 
calculi,  which  are,  at  any  rate,  superficially  phosphatic,  though  it  must 
be  allowed  that  sometimes,  as  in  the  instance  before  referred  to,  such 
stones  become  absolutely  innocuous. 

The  pain  of  a  renal  stone  often  aflfects  habitual  posture.  The  sufferer 
may  seek  relief  by  lying  on  his  belly,  on  his  back,  or  on  the  unaffected 
side.  A  gentleman  told  me  that  in  his  attacks  of  pain,  which  came  on 
with  daily  regularity,  he  *' lay  on  the  floor  and  wriggled  like  a  worm." 
Sometimes  positions  are  habitually  taken  which  have  an  appearance  of 
constraint,  but  which,  as  has  been  taught  by  sad  experience,  are  those  in 
which  the  injured  organ  has  to  bear  least  pressure.  A  gentleman  thus 
affected  observed  that  in  sitting  he  always  instinctively  lounged  to  one 
side,  while  in  walking  he  had  a  peculiarity  of  gait  by  which  he  could  be 
recognised  at  a  distance,  due  to  a  lateral  bend  of  the  body,  the  shoulder 
of  the  affected  side  being  the  higher.  Another  patient  habitually  sat  with 
the  knee  of  the  affected  side  held  up  by  his  clasped  hands,  thus  relaxing 
the  muscles  of  the  abdomen.  Sometimes  pressure  gives  relief,  as  in  the 
case  of  a  gentleman  who  found  most  ease  while  kneeling  upon  a  chair 
with  his  abdomen  bent  over  the  back. 

In  some,  fortunately  rare  cases,  the  pain  caused  by  a  renal  calculus  is 
of  almost  unendurable  severity.  It  is  not  always  easy  to  explain  the  dif- 
ferences which  are  observed  in  this  respect.  A  distinguished  member  of 
■our  own  profession,  who  has  been  aware  for  some  thirty  years  of  the  pres- 
ence of  stone  in  one  kidney,  and  has  carried  on  a  laborious  practice 
under  circumstances  of  bodily  suffering  by  which  many  men  would  have 
been  rendered  incapable  of  any  sustained  pursuit,  describes  the  pain, 
which  originates  in  one  lumbar  region  and  passes  horizontally  outwards 
and  forwards,  as  being  of  an  extreme  acuteness,  like  pain  ordinarily  de- 
scribed as  neuralgic.  Attacks  of  intense  agony  frequently  recurred,  the 
more  often  when,  from  other  circumstances,  the  general  health  was  be-- 
low  par,  necessitated  an  immediate  interruption  of  business  or  pleasure, 
and  a  recourse  to  chloroform  at  the  earliest  available  moment.  Such  at- 
tacks often  occurred  at  night,  inasmuch  that  for  many  months  together 
this  gentleman  never  dared  to  go  to  bed  without  a  bottle  of  chloroform 
under  his  pillow,  the  inhalation  of  which  he  found  to  be  the  only  mitiga- 
tion of  his  sufferings.  The  duration  and  intensity  of  the  suffering  which 
may  arise  from  a  renal  calculus  are  exemplified  in  the  life  of  Robert  Hall, 
the  eloquent  Nonconformist,  of  whom  it  is  said  that  from  his  infancy  to 
his  death,  in  his  sixty-seventh  year,  he  was  seldom  free  from  severe  pain. 
When  he  was  six  years  old  he  often  had  to  lie  down  on  his  road  to  school 
to  relieve  a  pain  in  his  back,  and  through  his  subsequent  life  this  pain, 
which  increased  with  his  years,  was  seldom  absent,  and  often  agonizing. 
It  was  aggravated  by  sitting  or  standing;  he  could  seldom  sit  for  more 
than  an  hour  together,  and  passed  a  large  proportion  of  his  life  in  a  hori- 
zontal position.  He  wrote  one  of  his  most  celebrated  sermons  lying  upon 
the  floor.  He  was  accustomed  to  stretch  himself  upon  three  chairs,  the 
l)osture  in  which  he  found  most  relief.  For  more  than  twenty  years  he 
never  passed  a  whole  night  in  bed,  but  was  compelled  after  a  short  sleep 
to  get  up  and  seek  ease  in  his  favorite  attitude.  Intolerant  as  he  was 
of  sitting,  he  often  found  relief  from  walking,  and  it  was  even  thought 
for  a  time  that  horse  exercise  was  beneficial.     The  intensity  of  the  pain 


162  PATHOLOGICAL  RELATIONS  OF  RENAL  CALCULI. 

compelled  him  to  have  large  recourse  to  opium;  in  a  single  night  he  was 
known  to  take  nearl}^  four  ounces  of  laudanum.  He  found  alleviation 
also  from  smoking,  an  art  which  he  had  acquired  in  order  to  qualify 
himself  for  the  society  of  Dr.  Parr.  The  sufferings  of  his  last  illness, 
which  was  mainly  dependent  upon  disease  of  the  aorta,  were  cruelly  aggra- 
vated by  his  inability  to  breathe  in  the  horizontal  posture,  which  was 
imperiously  demanded  by  the  lumbar  pain.  After  death,  the  cause  of 
his  sufferings,  which  during  life  had  remained  undiscovered,  was  found 
to  be  a  large,  rough  pointed  calculus,  which  entirely  filled  the  right  kid- 
ney. It  is  worthy  of  remark,  as  illustrative  of  the  frequent  coincidence 
of  renal  calculus  with  mental  disease,  that  this  gifted  man  was  twice  in- 
sane. 

Gastric  disturbances,  nausea,  vomiting,  and  various  forms  of  indiges- 
tion, are,  next  to  pain — with  which  tiie  disturbance  of  stomach  is,  as 
Prout  observes,  generally  commensurate — the  most  frequent  symptoms 
of  renal  calculus.  Tiie  sympathy  between  the  stomach  and  kidney, 
under  these  circumstances,  probably  depends  upon  their  community  of 
supply  by  the  pneumogastric  nerve,  the  irritation  of  the  renal  being  re- 
flected to  the  gastric  branches.  The  action  of  the  stomach  is  variously 
interfered  with. 

Vomiting  frequently  occurs,  often  with  the  evacuation  of  nearly  pure 
bile;  this  being  in  some  cases  so  far  the  most  prominent  symptom  that 
its  renal  origin  may  escape  notice.  Nausea,  acidity,  flatulence,  and  gas- 
trodynia  occur  in  every  permutation,  being,  as  sometimes  necessarily  hap- 
pens, enhanced  by  the  gouty  disposition  of  the  patient.  Attacks  of 
stomach  disturbance  are  often  coincident  with  pain,  hematuria,  and  the 
other  signs  of  increased  renal  irritation. 

Eetraction,  pain,  and  variously  perverted  sensations  in  the  testicle  of 
the  side  affected  are  sometimes  early  and  prominent  signs  of  renal  calcu- 
lus. When  the  pain  is  long  continued  the  affected  testicle  is  apt  to  swell 
and  become  tender.  Sometimes,  instead  of  drawing  up,  the  scrotum  be- 
comes relaxed  or  affected  with  a  sense  of  coldness  or  numbness.  These 
sensations  are  often  associated  with  numbness  or  pain  on  the  inner  sur- 
face of  the  thigh.  Neuralgia  of  the  testicle  has  been  known  as  the  chief 
svmptom  of  renal  calculus,  as  in  a  case  of  renal  lithotomy  reported  by 
Mr.  Butlin.' 

Irritation  of  the  bladder,  and  that  to  a  distressing  degree,  may  be  a 
direct  or  indiiuct  consequence  of  stone  in  the  kidney.  A  young  woman 
died  under  my  care  in  St.  George's  Hospital  witli  symptoms  of  pyelitis, 
which  might  have  been  the  result  of  either  stone  or  tubercle;  but  her 
distress  was  almost  wholly  vesical;  the  urine,  which  was  persistently 
purulent,  was  passed  with  much  frequency,  pain,  and  diflBculty,  and  the 
catheter  often  needed.  Both  kidneys  were  occupied  by  large,  rough 
stones;  the  bladder  and  urethra  were  perfectly  natural;  the  vesical 
trouble  wholly  of  renal  origin,  no  doubt  in  part  due  to  the  irritation  of 
the  purulent  and  alkaline  urine. 

Another  result  of  renal  calculus  is  hiBmorrhage — less  profuse  than 
from  growths,  and  not  frequent  enough  to  cause  marked  depletion  or 
call  for  styptic  remedies. 

As  an  exception  to  this  statement  I  may  mention  the  case  of  a  lady 
who  was  reduced  by  habitual  though  not  profuse  haemorrhage,  the  re- 
sult of  a  renal  stone,  to  a  condition  of  exceeding  anaemia,  as  evinced  both 


'  Clin.  Trans,  vol,  xv. 


PATHOLOGICAL  RELATIONS  OF  RENAL  CALCULI.  163 

in  appearance  and  constitutional  symptoms,  and  was  greatly  benefited  by 
iron. 

The  haemorrhage  of  calculus  is  rather  constant  or  oft-repeated  than 
copious,  though  in  all  these  respects  it  is  subject  to  great  variation.  In 
some  cases  it  is  seldom  absent,  in  others  never  present;  in  some  it  consti- 
tutes almost  the  only  evidence  of  a  renal  concretion. 

The  great  peculiarity  of  liasmaturia  from  this  cause  is  its  dependence 
upon  movement;  it  recurs  with  exercise  or  locomotion  and  ceases  with 
rest.  Thus  the  urine  is  found  to  be  bloody  during  the  day  or  on  going 
to  bed,^  rather  than  during  the  niglit  or  on  rising  in  the  morning.  This 
is  the  converse  of  what  occurs  as  tiie  result  of  cancer  or  villous  disease; 
the  supine  posture  of  sleep  appears  to  favor  the  accumulation  of 
blood  in  renal  growths,  whence  they  are  more  apt  to  bleed  in  the  niglit 
than  the  day. 

The  blood  from  renal  calculus,  though  sometimes  enough  to  tint  the 
urine  in  a  manner  alarming  to  the  patient,  is  in  other  cases  in  so  small 
quantity  that  it  cannot  be  detected  except  with  the  microscope.  The 
blood  is  yielded  by  the  mucous  membrane  of  the  pelvis  and  not  by  the 
kidney-tubes;  it  is  consequently  not  moulded  into  casts,  but  occurs  as  an 
incoherent  sediment  mixed,  should  the  haemorrhage  be  large,  with 
minute  indefinite  clots.  Tiie  blood  is  generally  less  intimately  mixed 
with  the  urine  than  occurs  when  hasmaturia  is  the  result  of  disease  of 
the  substance  of  the  kidney;  it  less  often  forms  the  persistently  smoky 
or  porter-colored  mixture  so  often  found  with  albuminuria;  but  the  glo- 
bules readily  subside  and  form  a  colored  stratum,  in  which  sometimes 
shreddy  clots  may  be  detected,  superincumbent  urine  having  its  natural 
appearance.  The  deposit  is  coffee-colored  when  the  urine  is  acid;  red 
or  pinkish  when  it  is  alkaline. 

Different  stones  are  accompanied  with  different  tendencies  to  haem- 
orrhage. Oxalate  of  lime,  from  its  crystalline,  spiky,  or  tuberculated 
exterior,  produces  most,  phosphatic  calculi  the  least.  Concretions  com- 
posed of  or  coated  with  phosphates,  associated  as  they  necessarily  are  with 
local  inflammation,  are  usually  surrounded  with  thickened  and  altered 
mucous  membrane,  which  is  more  apt  to  yield  pus  than  blood. 

It  is  to  be  noted  as  a  possible  source  of  erroneous  diagnosis  that  the 
local  irritation  of  stone  will  sometimes  cause  a  cast  or  two,  which  I  have 
sometimes  noticed  to  contain  epithelium,  to  show  themselves  in  the 
urine,  even  though  it  be  practically  certain  that  there  is  no  disease  gen- 
eral to  the  renal  structure. 

It  may  be  worth  while  briefly  to  sum  up  the  distinctions  by  which  the 
haematuria  of  stone  can  be  distinguished  from  other  conditions  of  renal 
bleeding.  (See  chapter  on  Ilgematuria.)  I  presume  that  in  the  case  un- 
der consideration  it  has  been  ascertained,  by  the  absence  of  symptoms 
referable  to  the  bladder,  that  the  blood  proceeds  from  the  kidney.  The 
common  causes  other  than  calculus  of  the  discharge  of  blood  from  this 
organ  are  albuminuria,  j)urpura  or  scurvy,  intermittent  haematuria,  tu- 
berculous, malignant,  or  villous  growths.     In  deciding  between  either  of 

'  Renal  haemorrhage,  presumbly  from  stone,  may  come  on  without  external 
provocation,  and  possibly  be  preceded  by  some  sensation  which  will  enable  the 
experienced  patient  to  foretell  its  advent.  A  distinguished  army  surgeon,  who 
has  presumptive  evidence  of  a  renal  calculus,  finds  that  an  attack  of  haematuria 
is  usually  preceded  by  sleeplessness;  a  night  or  possibly  two  during  which  he  is 
sleepless,  but  not  restless  or  otherwise  disturbed,  is  followed  by  pain  at  a  spot 
in  one  renal  region,  and  that  by  haemorrhage. 


164:  PATHOLOGICAL  RELATIONS  OF  RENAL  CALCDI. 

these  and  stone  we  shall  have  regard  to  the  existence  of  tlie  symptoms  or 
history  of  renal  calculus,  or  of  the  jiassage  of  gravel.  Beyond  this  every 
other  form  of  haematuria  has  characters  which  distinguish  it  from  the 
liaematuria  of  stone. 

With  albuminuria,  beyond  the  evidence  afforded  by  casts,  the  urine 
contains  more  albumin  than  the  superadded  blood  suffices  to  account  for 
and  remains  albuminous  when  it  has  ceased  to  be  bloody. 

With  purpura  or  scurvy,  as  in  albuminuria,  the  blood  is  apt  to  be  in- 
volved in  casts;  besides  which  hasmorrhages  occur  at  the  same  time  in 
other  parts  of  the  body. 

With  intermittent  haematuria  the  blood-corpuscles  are  destroyed; 
with  calculus,  they  remain  distinct. 

AVitli  regard  to  malignant  or  villous  disease  the  distinction  is  often  a 
matter  of  some,  though  seldom  of  insuperable,  difficulty.  Growths  cause 
moi'e  profuse  haemorrhage  than  does  a  stone,  often  producing,  as  a  stone 
seldom  does,  conspicuous  signs  of  anaemia.  Bleeding  from  a  growth  is 
apt  to  occur  during  sleep,  at  which  time  the  bleeding  of  calculus,  de- 
pending as  it  does  on  movement,  isdiminished  or  quiescent.  The  urinary 
sediment,  examined  with  the  microscope,  especially  during  the  intervals  of 
haemorrhage,  will  sometimes  display  the  vascular  loops  characteristic  of 
villous  disease.  Should  the  growth  be  cancerous,  and  of  the  bladder, 
large,  round,  or  flat  nucleated  cells  may  be  abundantly  seen  in  the  urine; 
or  even  considerable  fragments  of  cancerous  growth  may  be  expelled.  If 
of  the  kidney  the  growth  is  usually  sarcomatous,  and  the  escape  of  cells 
or  any  distinctive  elements  with  the  urine  is  of  exceeding  rarity.  The 
presence  of  the  ''malignant  cachexia"  is  a  guide,  though  a  somewhat 
untrustworthy  one.  The  presence  of  a  tumor  in  the  renal  region,  to- 
gether with  haemorrhage,  may  be  genei-ally  taken  as  indicating  a  growth; 
for  though  a  tumor  may  be  produced  by  calculous  obstruction,  it  does  not 
often  happen  tiiat  blood  proceeds  from  a  kidney  thus  obstructed. 

The  distinction  between  the  hemorrhage  of  scrofulous  or  tuberculous 
disease  and  that  of  stone  may  be  of  more  difficulty.  With  both  the 
blood  may  be  mixed  with  pus;  and  with  stone  it  is  possible  that  there 
may  be  a  febrile  temperature,  such  as  is  more  common  with  tubercle. 
The  elfoct  of  movement  is  a  guide;  while  with  tubercle  hoBmorrhage  is 
more  often  absent,  and  when  present  is  less  often  repeated  than  with 
stone. 

The  symptoms  which  have  been  described,  those  which  a  stone  ])ro- 
duces  by  moving  in  the  pelvis  oi-  irritating  the  membrane  by  ill-adjusted 
pressure,  may,  should  the  stone  enter  the  ureter,  become  exaggerated  and 
accompanied  by  agonizing  pain  and  much  constitutional  disturbance.  To 
the  symptoms  of  a  pelvic  calculus,  the  results  of  spasmodic  contraction 
of  the  ureter  are  superadded.  Spasm  of  involuntary  muscle,  always 
])ainful,  is  never  more  so  than  when  the  ureter  is  the  subject  and  a  calcu- 
lus the  cause.  The  painful  passage  of  stone  or  sand  along  this  duct  con- 
stitutes what  is  described  as  a  fit  of  the  gravel.  The  patient  is  attacked, 
l)erhaj)S  suddenly,  after  some  exertion,  jerk,  or  unusual  movement,  or 
withuot  any  external  ])rovocation,  with  acute  pain  in  the  loins,  or  in  the 
course  of  the  ureter,  which  shoots  towards  the  testicle,  groin,  and  blad- 
der, and  amounts  in  some  cases  to  as  severe  agony  as  the  human  body 
has  the  power  of  making  for  itself.  It  may  be,  as  Prout  says,  of  such  an 
overwhelming  nature  as,  together  with  the  sickness  which  accompanies 
it,  to  paralyze  the  stoutest  iiulividual.  The  pain  is  not  at  first  associated 
with  tenderness  to  any  marked  extent,  though  it  may  become  so  after  a 


PATHOLOGICAL  RELATIONS  OF  RENAL  CALCULI.  165 

time.  The  attitude  and  manner  of  the  sufferer  who  moves  in  restless 
anguish  are  cliaracteristic  of  colic  rather  than  inflammation.  There  is 
much  constitutional  or  nervous  disturbance.  Sliivering  early  comes  on, 
or,  short  of  actual  shaking,  horripilation,  and  a  feeling  of  cold,  to  be 
succeeded  after  a  time  by  more  or  less  febrile  reaction.  With  the  cold 
the  patient  becomes  faint,  or  even  actually  faints,  and  may  display  other 
sigus  of  nervous  disturbance,  in  the  form  of  epileptic  seizures  or  jiassing 
delirium.  A  medical  friend,  one  whoso  nerves  are  not  easily  shaken, 
described  his  sensations  on  passing  a  mulberry  calculus  as  an  altogether 
novel  experience.  While  in  a  hi})-bath  he  was  seized  with  an  intolerable 
exacerbation  of  the  pain,  with  a  rushing  in  the  head  and  wild  confusion 
of  mind,  in  which  he  sprang  from  the  bath  and  ran  unclothed  out  of  the 
room.  A  few  minutes  afterwards  he  passed  water  and  with  it  the  stone, 
and  was  himself  again.  The  unbearable  pang  marked  the  passage  through 
the  narrow  termination  of  the  ureter.  The  stomach  early  sympathizes 
in  the  disturbance,  nausea  and  sometimes  urgent  and  repeated  vomiting 
being  among  the  first  symptoms.  When  the  stone  is  passing,  especially 
from  the  left  kidney,  there  is  often  so  much  discomfort  and  distention 
of  the  bowel  that  the  attack  is  looked  npon  as  intestinal  colic,  until  the 
expulsion  of  the  calculus  provides  the  interpretation.  There  is  much  ir- 
ritation of  the  bladder,  small  quantities  of  dark  or  bloody  urine  being 
frequently  passed.  The  pain,  as  tlie  attack  continues,  moves  down- 
Avards,  and  sometimes  terminates  suddenly  during  a  fit  of  retching,  with 
a  piercing  exacerbation.  The  ureter  is  narrowest  at  its  lower  end,  where 
it  passes  through  the  coats  of  the  bladder.  At  this  spot  the  stone  is  par- 
ticularly apt  to  stick.  Having  passed  this  strait  the  stone  falls  into  the 
bladder,  and  the  attack  is  at  an  end.  The  time  occupied  by  the  process 
varies  much,  the  symptoms  are  sometimes  over  in  an  hour  or  two;  they 
sometimes  occupy  days,  and  have  even  been  known  to  last,  with  little 
intermission,  as  long  as  three  weeks. 

The  pain  is  not  always  such  as  has  been  described.  After  the  first 
attack  the  symptoms  are  much  milder;  the  ureter  becomes  dilated  and 
tolerant.  Even,  for  tlie  first  time,  small,  smooth  stones  are  sometimes 
passed  without  any  of  the  characteristic  symptoms.  Of  all  calculi  those 
of  oxalate  of  Hme  cause  the  most  distress  in  their  descent;  uric  acid,  as  a 
rule,  the  least. 

The  effects  of  suppression  of  urine,  as  caused  by  the  impaction  and 
movement  of  renal  calculi,  are  separately  considered  (p.  172). 

The  following  narrative  was  written  at  my  suggestion  by  a  respected 
member  of  the  medical  profession,  who  has  frequently  passed  small  crys- 
talline calculi  of  oxalate  of  lime.  It  illustrates  in  a  graphic  manner  many 
of  the  symptoms  which  attend  the  com])laint  in  a  not  very  severe  form. 
It  is  to  be  premised  that  this  gentleman  had  been  in  the  habit  of  drink- 
ing hard  water,  and  that  freely  : — 

'  One  day  in  February,  1863,  then  having  taken  a  sixteen  or  seventeen  mile 
country  walk,  soon  after  going  to  bed  I  was  seized  with  a  severe  pain  in  the  right 
lumbar  region,  extending  down  the  groin  and  through  the  pelvis.  This  was  ac- 
companied by  retraction  of  the  testicle  on  that  side  to  such  a  degree  that  it  was 
almost  worse  than  the  pain.  On  getting  out  of  bed  I  could  hardly  stand  upright; 
however,  I  managed  to  procure  some  twenty  drops  of  laudanum,  and  soon  after 
fell  to  sleep.  In  the  morning  there  was  asHght  appearance  of  blood  in  the  urine, 
which  was  very  acid.  I  was  prescribed  some  alkaline  sahne  with  tincture  of 
henbane,  and  in  the  course  of  a  few  days,  after  some  more  pain  at  night,  relieved 
by  liot  hip  bath  and  laudanum,  I  passed  a  small  calcukis.  After  this  I  was  in  my 
sual  healtli  and  vigor  for  I  suppose  a  year  or  more,  when  I  had  much  the  same 


166  PATHOLOGICAL    KKLATIONS    OF    RENAL    CALCULI. 

train  of  symptoms,  but  I  think  if  anything  less  pain.  The  next  attack  was  again 
in  about  a  year,  when  I  was  resident  at  the  hospital  and  taking  less  walking  ex- 
ercise than  formerly.  Up  to  this  time  I  had  done  very  little  by  way  of  treatment, 
but  as  I  had  several  attacks  one  after  the  other,  I  consulted  Dr.  Dickinson,  and  at 
his  instigation  put  myself  under  regimen.  I  left  off  beer,  fruit,  pastry,  reduced 
my  consumption  of  vegetables,  drank  distilled  water,  and  took  nitro-hydrochloric 
acid.  This  treatment  I  continued  for  some  months  during  the  early  part  of  1865, 
and  I  certainly  for  a  time  was  much  better,  and  under  the  microscope  the  oxalate 
of  lime  crystals  were  scarcely  to  be  found,  wliereas  formerly  tliey  had  been  nu- 
merous. Towards  the  end  of  the  year  I  suffered  a  good  deal  again,  and  having 
lived  now  nearl}'  two  years  in  the  hospital,  felt  generally  a  little  out  of  health, 
though  I  was  not  for  a  single  da}'  disabled  from  following  my  duties.  At  the 
end  of  1865  I  left  town,  and  went  to  Bath  for  a  week.  During  this  time,  after 
soakmg  for  some  time  in  the  hot  bath  there,  I  passed  a  rather  longer  calculus 
than  I  had  before  discharged.  After  tl)is  I  went  to  live  at  home,  and  for  a  long 
time  was  quite  free  from  any  symptoms,  and  so  by  degrees  became  careless  of 
any  lestriction  in  diet.  I  generally  found,  however,  that  champagne  or  anything 
of  that  nature  would  cause  vague  lumbar  pains,  and  I  think  I  had  one  or  two 
sliglit  attacks  of  calculus,  but  1  forget;  I  took  no  medicine,  and  did  not  examine 
the  urine  by  microscope. 

"  In  March,  1868,  I  had  an  attack  of  scarlatina,  but  no  renal  mischief,  and  in 
numerous  examinations  never  detected  any  albumin  in  the  water.  In  August  of 
that  year,  after  a  rough  steamboat  journey  to  Scarborough,  I  had  some  sharp 
lumbar  pain,  next  day  detected  blood  in  the  urine,  and  a  day  or  two  after  passed 
a  small  calculus,  having  carried  it  about  in  my  bladder  some  twenty -four  hours 
or  more.  About  Christmas  that  year  1  began  to  suffer  from  sciatica  on  tlie  right 
side,  and  for  months  was  not  free  from  it.  Once  or  twice,  from  sheer  inability  to 
move,  I  stayed  indoors  all  day,  but  generally  I  jnanaged  to  limp  about  as  usual. 
I  hail  at  first  no  renal  pain,  though  ic  came  on  subsequently.  When  the  sciatica 
was  not  very  severe.  I  contented  myself  with  some  restrictions  in  diet,  merely 
«uch  as  leaving  off  beer;  but  when  a  severe  attack  came  on  I  found  relief  from 
"Vin.  Colch.  S  ss;  Pot.  Bic,  Sodse  Bic,  Pot.  Nit.  aa  gr.  xv.;  Sp.  Amnion.  Ar. 
3  ss;  Aq.  ad  3  iss;  once  or  twice  a  day,  and  the  application  or  camphor  liniment, 
and  laudanum  over  the  nerve  at  night.  Tliis  generally  produced  relief  in  a  day 
or  two.  After  going  on  in  this  way  for  some  months  I  passed  the  largest  calculus 
I  had  yet  discharged,  without  much  pain  or  any  sedative.  For  some  time  before 
it  passed,  any  unusual  exercise,  as  running,  dancing,  etc.,  was  sure  to  be  followed 
by  )»ain  in  the  kidney,  and  sciatica,  and  by  urine  the  color  of  claret.  Before 
finally  leaving  me,  the  calculus  remained  some  daj's  in  the  bladder,  jiroducing 
great  irritation,  and  constant  burning  pain  at  its  neck. 

"  After  getting  rid  of  this  calculus  I  was  much  better  for  some  time,  but  dur- 
ing the  next  twelve  months  I  passed  two  or  three  small  calculi  at  intervals,  pre- 
ceded generally  by  sciatica  of  two  or  three  days'  duration.  I  found  that  the 
colchicum  and  alkali,  etc.,  always  produced  relief.  In  July,  1870, 1  had  been  feel- 
ing rather  "  renal"  for  some  time,  and  one  day  sciatica  came  on  so  sharply  that 
having  to  walk  some  two  miles  gave  me  exquisite  torture,  besides  producing  a 
feeling  of  great  misery  and  depression.  A  hot  bath,  colchicum,  etc.,  relieved  me, 
and  in  a  day  or  two  I  was  rewarded  with  a  calculus.  In  September  I  spent  a 
"week  walking  about  twenty  miles  per  diem  in  the  Isle  of  Wight,  and  a  day  or  two 
:ifter  my  return  got  rid  of  a  small  calculus,  with  scarcely  any  pain  or  trouble.  To 
sum  up  then,  the  attacks  seem  to  come  on  indiscriminately  in  summer  or  winter, 
spring  or  autumn.  And  the  calculus  passes  down  the  ureter  either  day  or  night, 
though  generally  by  night.  The  pain  is  seldom  sufficienth'  great  to  interfere 
•with  my  appetite  or  rest,  though  generally  producing  some  depression  of  spirits, 
particularly  at  the  commencement  of  the  attack.  Often  a  slight  degree  of  hee- 
maturia  is  the  earliest  indication,  sometimes  it  is  the  pain.  I  have  noticed  that 
the  amounts  of  pain  or  of  hiemorrhage  are  not  always  proportionate  to  the  size 
of  the  calculus,  or  to  each  other;  sometimes  there  being  more  hsematuria,  some- 
times more  pain." 

Modes  of  Death. 

Tlie  modes  by  which  renal  stone  kills  and  their  relative  frequency 
may  be  fairly  represented  by  the  post-moi-iem  experience  of  St.  George's 
Hospital,  which  has  been  systematically  recorded  since  the  year  1842.  Of 


PATHOLOGICAL    RELATIONS    OF    RENAL    CALCULI.  167 

sixty  persons  (see  page  158),  in  whose  bodies  stones  were  found,  twenty 
had  died  mainly  by  their  means,  forty  from  causes  unconnected  with 
ihem. 

Causes  of  Death  in  20  Fatal  Cases  of  Renal  Calculus. 

Number 
Immediate  cause  of  death.  of  cases. 

Pyelitis,  uncomplicated, 3 

"         +  Perinephritic  abscess, 3 

"         +  Lumbar  abscess, 1 

"         +  Suppurative  peritonitis  (rupture  into  peritoneum),         .  2 
"        -l-Ulceration  into  bowel,       .         .         .         .        .        .         .1 

"         +Lardaceous  disease, 2 

"         +  Cystitis, 1 

"         +General  tuberculosis, 1 

"         4- Granular  kidney 1 

Pyaemia, 1 

Suppression  of  urine  (calculi  in  both  kidneys),          ....  1 

Atrophy  of  kidneys,     ..........  1 

Mania -f-enlarged  prostate  and  retention, 1 

Rupture,  from  blow,  of  kidney,  which  contained    many  pointed 

calculi, 1 

Of  the  twenty  who  died  of  stone,  sixteen  did  so  in  consequence  of 
suppuration;  pyelitis  being  present  in  all,  and  in  three  the  chief  cause  of 
death.  The  extension  of  suppuration  beyond  the  kidney  into  the  cir- 
cumjacent tissue,  the  peritoneum,  the  bowel,  and  the  loin,  is  represented 
by  seven  cases — about  a  third  of  the  whole.  Lardaceous  disease  was 
recognized  only  in  two  instances;  many  of  the  observations  were  made  at 
an  early  date;  but  it  may  bo  safely  stated  as  the  result  of  recent  experi- 
ence tliat  death  rarely  ensues  from  pyelitis  or  chronic  extra-renal  suppura- 
tien  without  more  or  less  of  it.  Fibrotic  atropliy,  with  some  dilatation 
of  the  pelvis,  with  or  without  the  development  of  the  granular  condition 
marked  organically  and  clinically,  is  a  distinct  result  of  renal  stone,  and 
is  represented  in  the  table.  Pyasmi a  appeal's  a.s  the  cause  of  death  on  the 
warrant  of  a  case  in  which  this  condition  jiroved  fatal,  but  for  which  no 
cause  could  be  discovered  though  laboriously  sought,  save  a  renal  stone, 
which  had  been  lately  productive  of  bleeding.  The  locally  disseminated 
suppuration  of  the  "surgical  kidney"  finds  no  place  as  a  consequence  of 
renal  stone  either  within  the  table,  or  so  far  as  I  know  outside  it.  It  was 
found  once  in  conjunction  with  renal  calculus,  but  there  was  also  pro- 
static disease,  to  wiiich  the  suppurative  lesion  Avas  at  least  in  part  to  be 
attributed.  Traumatic  suppuration  presents  itself  by  chance.  The  kid- 
ney which  contained  the  spiked  calculi,  represented  at  page  138,  singu- 
larly ill-suited  as  they  must  have  rendered  it  to  endure  violence,  was 
ruptured  thirty  days  before  death  by  the  fall  of  a  brick.  The  cortex  was 
iound  to  be  sprinkled  with  miliary  abscesses. 


CHAPTER    XIII. 

ON  CERTAIN   RESULTS   OF   RENAL   CALCULL 

Calculous  Pyelitis.' 

The  dilatation  of  the  kidney  which  results  from  stone  is  often  accom- 
panied with  suppuration  of  the  pelvic  mucous  membrane,  set  up  by  the 
contact  of  the  accumulated  and  decomposing  urine.  Suppuration  under 
these  circumstances  is  generally  coincident  with  much  extension  and 
atrophy  of  the  kidney  ;  the  converse  also  holds  that  much  extension  from 
calculous  obstruction  is  seldom  reached  without  more  or  less  suppuration. 
The  lining  membrane  first  becomes  vascular,  traversed  by  vessels  which 
in  extreme  cases  may  be  so  numerous  and  turgid  that  the  surface  looks 
almost  black.  Later  appears  the  smooth,  opaque,  creamy  surface  of 
supi)uration. 

The  symptoms  of  early  calculous  pyelitis  are  those  of  pyelitis  added  to 
those  of  stone.  Later,  it  is  not  unknown  for  the  stone  to  have  escaped 
or  to  have  fallen  into  quietude  and  oblivion,  the  pyelitis  only  remaining 
evident.  The  pyelitis  is  first  displayed  by  the  urine,  which  contains 
mucus,  though  there  be  no  signs  of  vesical  inflammation.  With  this  the 
microscope  may  show  epithelial  cells  of  various  forms  (see  woodcut,  page 
20),  and  perhaps  blood-corpuscles.  The  mucus,  especially  abundant 
when  the  stone  is  of  oxalate  of  lime,  sometimes  makes  its  exit  in  tenacious 
gelatinous  masses,  which  may  cause  scarcely  less  distress  in  traversing  the 
ureter  than  stony  concretions.  After  a  longer  or  shorter  time,  particularly 
if  the  urine  be  retained  in  the  pelvis  in  considerable  bulk,  the  mucus  is 
replaced  by  pus.  There  is  generally  little  doubt  as  to  the  renal  origin  of 
the  discharge.  The  pus,  when  the  condition  is  fully  established,  is  apt 
to  be  eminently  "laudable,"  unmixed  with  such  foul  and  stringy  dis- 
charge as  proceeds  from  the  bladder,  its  corpuscles  displayed  in  a  regular 
and  typical  form.  Such  matter  separates  readily  and  distinctly  from  the 
supernatant  urine,  which  remains  acid  and  inoffensive. 

Urine  of  this  nature,  passed  as  it  often  is  without  frequency  or  any 
vesical  disturbance,  cannot  fail  to  be  regarded  as  of  renal  origin,  a  view 
which  will  probably  be  corroborated  by  the  presence  of  unmistakably 
renal  symptoms.  Less  often  the  urine  is  peculiarly  offensive,  and  the 
discharge  broken  down  beyond  recognition,  as  the  result  of  accumulation 
and  putrefaction  in  the  pelvis.  In  such  cases  it  often  escapes  inter- 
mittently. 

There  is  usually  pain  either  in  the  affected  loin  only,  or  sometimes  in 
both,  of  a  dull  continuous  kind  :  or  there  may  be,  in  the  same  situation, 
a  sense  of  weight  or  of  heat.  Uneasy  sensations  are  also  frequently  felt 
in  the  course  of  the  ureter  and  in  the  testicle.    With  these  there  is  some- 

'  See  also  chapter  on  "  Pyelitis,"  p.  16. 


ON    CERTAIN    RESULTS    OF    RENAL    CALCULI.  i09 

times  slight,  sometimes  severe  and  continuous  febrile  disturbance,  with 
gradual  loss  of  strength,  loss  of  appetite,  nausea,  and  even  vomiting. 
Irritation  of  the  bladder,  apparently  the  result  of  nervous  sympathy, 
evinced  by  frequency  of  micturition,  sometimes  occurs,  especially  in  the 
early  stage  ;  it  sometimes  is  sufiQciently  persistent  and  severe  to  raise  a 
suspicion  of  disease  of  the  bladder,  though  this  organ  be  perfectly  healthy 
This  is  especially  the  case  when  tlie  urine  is  alkaline. 

It  will  be  seen  from  the  preceding  description  that  there  is  seldom  any 
doubt  as  to  the  renal  seat  of  calculous  pyelitis,  but  that  a  difficulty  may 
occur  in  distinguishing  calculous  from  tubercular  suppuration.  Should 
this  fail  to  be  solved  by  the  early  history  of  the  case,  it  may  be  useful  to 
bear  in  mind  that  the  discharge  of  calculous  pyelitis  often  intermits, 
while  that  of  tubercular  disease  is  continuous.  Besides  this  calculous 
suppuration  is  more  protracted  than  tubercular,  and  it  usually  leaves  the 
bladder  healthy,  while  with  tubercular  disease  this  organ  generally  be- 
comes involved. 

The  production  of  pus  within  the  distended  and  attenuated  kidney 
gives  rise  to  further  consequences.  The  obstruction,  whether  it  be  a 
stationary  calculus  or  a  stricture  which  has  resulted  from  the  temporary 
lodgment  of  one,  may  be  complete  and  permanent,  allowing  no  fluid  to 
escape  at  any  time;  or  it  may  present  an  obstruction  which  will  only 
yield  to  extreme  pressure,  so  that  the  contents  of  the  cavity  generally  re- 
tained will  escape  at  intervals,  when  the  needful  vis  a  tergo  has  accumu- 
lated; or  it  may  be  that  the  constriction  never  amounts  to  an  absolute 
dam,  but  allows  the  contents  of  the  cyst  habitual  though  not  free  exit; 
finally,  the  stone  may  have  gone  on  its  way,  and  left  no  narrowing.  The 
symptoms  of  the  disease  and  the  prospects  of  the  patient  vary  materially 
with  these  circumstances.  Next  to  an  unobstructed  channel,  it  is  prob- 
ably best  that  it  should  be  closed.  The  impediment  had  better  be  quite, 
than  nearly,  insurmountable.  If  there  is  no  outlet  it  may  happen  that 
the  production  of  pus  will  after  a  time  cease  for  want  of  room,  the- 
watery  part  subsequently  disappearing,  and  the  atrophied  kidney  col- 
lapsing upon  putty-like  matter,  in  which  a  stone  may  be  imbedded,  the 
whole  forming  a  useless  but  perfectly  quiescent  and  innocuous  mass. 
Under  less  fortunate  circumstances  the  imprisoned  matter  may  make  its 
way  to  the  surface  of  the  body,  or  may  reach  the  bowel  or  peritoneum. 
Of  such  results  I  shall  speak  presently. 

When  the  obstruction  is  partial  the  secretion  of  urine  is  less  com- 
pletely arrested,  and  the  kidney  may  fill  and  empty  many  times  with 
successively  increasing  distention.  The  intermitting  discharge  of  pus 
which  happens  in  these  cases,  with  intervals,  often  lasting  for  months, 
during  which  the  urine  is  natural,  and  the  patient,  perhaps,  apparently 
well,  is  very  characteristic  of  the  disease.  An  example  of  this  intermit- 
tence  is  afforded  in  the  case  of  the  old  woman  whose  kidney  formed  a 
tumor,  thought  to  be  ovarian  (referred  to,  p.  55). 

When  the  nature  of  the  obstacle  is  such  as  to  allow  of  a  continuous, 
but  not  a  free  discharge,  the  disease  exists  in  its  most  protracted  form.. 
There  is  not  enough  pressure  upon  the  walls  of  the  cyst  to  arrest  secre- 
tion, while  there  is  too  much  to  allow  of  any  contractile  })rocess.  The 
suppuration  may  be  profuse  and  long-continued,  pure  hiudable  pus  being 
habitually  passed  with  the  urine,  sometimes  for  years.  In  these  cases  the 
constitution  is  apt  to  suffer  from  the  drain,  and  general  lardaceous  de- 
position to  ensue.     It  may  happen  that  other  results  of  profuse  suppura- 


170  ON    CERTAIN    RESULTS    OF    RENAL    CALCULI. 

tion  follow.     The  patient  may,  with  or  without  lardaceous  intervention, 
fall  into  a  hectic  febrile  state,  succeeded  by  typhoid  prostration. 

We  have  little  clinical  knowledge  of  calculous  pyelitis  existing  apart 
from  obstruction  of  the  ureter  by  present  stone  or  consequent  stricture. 
The  mere  mechanical  irritation  of  the  calculus  seldom  seems  enough  by 
itself  to  kcej)  up  continued  su})puration.  Retention  and  decomposition 
of  urine,  impossible  while  the  ureter  is  open,  are  necessary.  It  is  some- 
times found  that  after  death,  perhaps  from  some  cause  unconnected  with 
renal  disease,  an  attenuated  kidney,  the  pelvis  of  which  still  bears  traces 
of  suppuration,  has  tightly  contracted  upon  a  stone,  the  pervious  ureter 
having  given  exit  to  the  once  cojiious  contents  of  the  cyst.  In  such  a 
case  the  wasting  of  the  gland  is  sufficient  record  of  past  retention.  The 
obstruction,  however,  has  been  overcome,  probably  by  the  passage  of  the 
occluding  stone,  the  pus  has  escaped,  the  kidney  has  contracted,  and 
though  useless  has  ceased  to  be  mischievous. 

On    Suppuration    from    Calculus    Extending    Beyond   the 

Kidney.' 

Pus  originating  m  the  pelvis  in  connection  with  a  stone  sometimes 
makes  its  way  out  of  the  kidney,  and  travels  in  various  directions.  This 
<jan  only  occur  when  the  ureter  is  either  completely  closed  or  much  ob- 
structed. The  pus  may  pierce  the  muscles  of  the  back,  and  make  its  exit 
through  the  skin  in  that  region.  It  may  enter  the  psoas  muscle  and  give 
rise  to  psoas  abscess,  which  scarcely  differs  from  that  which  is  so  com- 
monly associated  with  spinal  disease.  It  may  break  into  the  peritoneum. 
It  may,  if  belonging  to  the  right  kidney,  ulcerate  into  the  ascending  or 
transverse  colon  or  duodenum;  if  in  the  left,  into  the  descending  colon. 
It  has  been  known  to  traverse  thediapliragm.  and  make  its  way  out  by  the 
bronchial  tubes;  and  lastly,  it  has  been  stated,  though  not  on  conclusive 
evidence,  that  urine  and  calculous  matter  have  passed  from  the  kidney 
into  the  stomach,  and  thence  been  rejected  l)y  vomiting.  Of  these  events 
tlie  most  common  are  the  discharge  upon  the  loins  and  into  the  descend- 
ing colon.  Peritoneal  rupture  comes  next  in  order  of  frequency.  Pene- 
tration of  the  duodenum,  transverse  colon,  and  bronchial  tubes  is  com- 
paratively rare. 

The  opening  of  a  calculous  abscess  superficially  has  been  recorded  by 
liowship,  Brodie,  and  many  other  writers.  Sometimes  stones  have  made 
their  way  out  by  this  route,  and  the  patients  recovered,  but  more  often 
the  slow  and  exhausting  process  has  terminated  fatally. 

Dr.  S.  F.  Simmons^  records  the  case  of  a  woman  who  passed  seven 
small  calculi,  at  intervals,  from  a  sinus  in  the  left  loin,  and  Cheselden 
states  that  from  three  patients  he  removed  stones  "  whicii  had  made 
their  way  from  the  kidneys  to  tlie  integuments,  and  there  occasioned  an 
imposthumation."  A  calculous  abscess  usually  occupies  the  lumbar  re- 
gion, and  is  apt  to  be  mistaken  for  disease  of  the  spine.  A  woman, 
twenty-six  years  of  age,  died  in  St.  George's  Hospital,  under  the  care  of 
the  late  Mr.  Keale,  witli  a  lumbar  abscess,  which  was  thus  misinterpreted 
by  that  careful  and  acute  surgeon.  It  was  found,  however,  after  death, 
that  the  suppuration  had  proceeded  from  the  left  kidney,  the  outlet  of 
which  had  become  obstructed  by  several  large  calculi.     Matter  had   col- 

'  See  also  chapter  on  "  Perinephritis,  ^  p.  23. 
"P/aV.  Trans.,  1774,  p.  108. 


ON    CP:BTAIJSr    RESULTS    OF    KENAL    CALCULI.  171 

lectod  in  the  pelvis,  made  its  way  backwards  through  the  lumbar  muscles 
:and  penetrated  to  the  skin  in  this  region.  The  pus  lay  in  considerable 
quantity  around  the  kidney,  and  had  worked  its  way  upwards  to  the 
diaphragm,  the  complete  penetration  of  which  was  only  prevented  by 
some  adhesions,  which  had  closed  what  would  otherwise  have  been  an 
open  channel,  conducting  the  renal  pus  into  the  pleural  cavity. 

An  abscess  connected  with  renal  calculi  may  open  in  the  groin,  upon 
the  front  of  the  thigh,  near  the  hip;  or  upon  the  gluteal  region.' 

The  progress  of  the  disease  is  usually  excessively  protracted.  A  scanty 
discharge  has  been  known  to  flow  for  many  years  from  an  abscess  of  this 
nature.  Once  open,  such  sinuses  appear  to  have  little  tendeaey  to  close, 
though  in  some  cases  the  discharge  has  become  insignificant.  As  to 
diagnosis  it  is  probable  that  a  careful  consideration  of  the  antecedents 
would  in  most  instances  suffice  to  suggest  a  calculous  origin,  a  suggestion 
which  would  be  confirmed  by  the  absence  of  definite  spinal  symptoms. 

It  is  far  less  common  for  a  calculous  abscess  to  break  into  than  behind 
the  peritoneum.  When  this  usually  fatal  accident  happens  it  is  where 
the  kidney  has  been  much  dilated  and  the  peritoneum  tightly  stretched 
over  its  front  surface.  I  say  usually  fatal  accident,  for  it  is  not  impossi- 
ble for  the  rupture  to  be  so  guarded  by  adhesions  that  no  immediately 
evil  consequences  follow.  An  example  of  this  is  given  in  a  case  in  which 
a  calculus  made  its  way  across  the  peritoneal  cavity,  from  the  right 
kidney  into  the  colon.  It  more  often  happens,  however,  that  such  limita- 
tion is  absent  or  incomplete,  and  the  occurrence  fatal,  with  the  well- 
known  symptoms  of  peritonitis  in  the  acute  form  which  is  associated  with 
jierforation  of  the  hollow  viscera. 

A  calculous  abscess  in  the  right  kidney  may  open  into  the  duodenum. 
It  has  been  known  to  cross  the  peritoneal  cavity,  as  already  stated,  and 
find  an  exit  in  the  right  extremity  of  the  transverse  colon.  A  stone  in 
the  left  kidney,  or  matter  connected  therewith,  frequently  makes  its  way 
into  the  descending  colon,  where  it  lies  in  close  relation  with  the  dis- 
eased organ.  This  is  by  far  the  most  common  track  by  which  a  renal 
calculus  reaches  the  intestinal  canal.  It  is  a  rare  event  for  a  calculous 
abscess  to  reach  any  part  of  the  bowels  which  are  separated  from  the  kid- 
ney by  the  peritoneum,  since  perforation  of  the  serous  cavity  is  usu- 
ally, though  not  invariably,  the  last  injury  inflicted  by  a  renal  concre- 
tion. 

Penetration  of  the  descending  colon  by  a  calculous  abscess  is  a  com- 
mon and  probably  not  always  an  unfavorable  event.  The  apposition  of 
the  descending  colon  and  the  left  kidney,  behind  the  peritoneum,  gives 
facilities  for  this  mode  of  exit.  Instances  of  this  occurrence  are  fre- 
quently related  in  books  and  illustrated  by  jireparations. 

In  St.  Bartholomew's  Hospital  is  a  kidney  which  has  become  saccu- 
lated in  consequence  of  the  lodgment  of  a  calculus  in  the  mouth  of  the 
ureter.  Two  ulcerated  openings  connect  the  cavity  of  the  pelvis  with 
that  of  the  descending  colon.  During  life  there  had  been  frequent  at- 
tacks of  pain  in  the  loins,  which  had  been  as  often  relieved  by  the  escape 
of  pus  from  the  bowels. 

A  singular  connection  between  the  left  kidney  and  the  bowels  is  il- 
lustrated by  a  preparation  at  St.  Thomas's  Hospital.  The  pelvis  has  be- 
come dilated  from  calculous  obstruction,  and  has  become  the  seat  of  sup- 

'  Rayer  gives  an  instance  where  a  calculous  abscess  opened  both  in  the  loin 
and  upon  the  front  of  the  tliigh,  Maladies  des  Reins,  vol.  iii.  p.  285. 


172  ON    CERTAIN    RESULTS    OF    RENAL    CALCULL 

puration.  The  pus  made  its  way  through  the  anterior  wall  of  the  dilated 
pelvis,  and  formed  a  circumscribed  abscess  between  the  kidney  and  the 
descending  colon,  into  which  it  opened. 

I  am  not  acquainted  with  any  unequivocal  case  in  which  a  renal  cal- 
culus has  caused  a  perforation  of  the  stomach.  Vomiting  of  urine  is  a 
not  unknown  occurrence,  but  the  subjects  of  the  plienomenon  are  usu- 
ally hysterical  women,  and  the  route  from  the  kidney  to  the  stomach 
more  circuitous  than  they  would  have  believed.' 

As  often  happens  with  perinephritic  abscess,  let  it  depend  on  what 
it  may,  matter  of  calculous  origin  may  make  its  way  through  or  behind 
the  diaphragm,  and  thence  into  tlie  bronchial  tubes.  It  appears,  either 
because  the  matter  rises  along  the  spinal  muscles  and  thence  enters  the 
root  of  the  lung  without  crossing  the  pleural  cavity,  or  because  the 
pleural  cavity  becomes  under  the  process  of  perforation  securely  guarded 
by  adhesions,  that  the  bronchial  tubes  rather  than  the  serous  interspace 
become  the  recipients  of  pus  entering  the  thorax  from  below.  The 
passage  of  matter  from  below  to  above  the  diaphragm  is  perhaps  most 
familiar  in  connection  with  hepatic  abscess. 


Suppression  of  Urine  from  Calculi. 

Writers  of  the  ante -pathological  era  speak  of  paralysis  of  the  kidney 
as  if  that  gland  were  apt,  like  a  discontented  workman,  to  strike  though 
still  able  to  work  ;  but  it  has  been  shown  in  another  part  of  this  volume 
that  though  the  secretion  of  urine  may  be  temporarily,  or  even  finally 
arrested  by  constitutional  causes,  yet  that  it  never  stops  altogether  as 
the  result  of  renal  disease,  unless  the  outlets  are  blocked.  This  closure 
may  be  by  growths  or  clots,  but  in  by  far  the  larger  proportion  of  cases 
it  is  due  to  calculi,  or  to  the  injury  calculi  have  inflicted. 

An  obstruction  to  cause  suppression  must  occur  simultaneously  in 
connection  with  both  kidneys,  or  else,  should  it  refer  only  to  one,  the- 
other  must  have  been  destroyed  by  antecedent  disease. 

Such  renal  calculi  as  are  of  constitutional  origin,  uric  acid,  oxalate 
of  lime  and  cystine,  are  apt  to  occur  in  both  kidneys,  either  at  the  same 
time  or  successively. 

When  both  kidneys  are  simultaneously  affected,  the  stones  are  often 
so  far  symmetrical  that  both  ureters  are  closed  in  the  same  manner,  and 
to  the  same  extent. 

When  the  kidneys  are  successively  disabled  by  calculous  disease,  sup- 
pression occurs  only  on  the  incapacitation  of  the  second.  One  ureter 
may,  either  by  impacted  stone  or  consequent  stricture,  become  per- 
manently closed,  and  the  kidney  sacculated,  and  for  purposes  of  secre- 
tion practically  non-existent,  but  yet  no  serious  consequences  may  result^ 
unless  in  process  of  time  calculi  be  formed  also  in  the  second  kidney. 

'  Dr.  Sclater,  of  Pliiladelphia.  relates,  in  the  Trans,  of  the  College  of  Fhyai- 
cians  of  that  city  (vol.  i.  part  i.  p.  96;,  the  case  of  a  woman  with  retention  of 
urine.  Whenever  the  catheter  was  withheld,  urine,  often  mixed  with  urinary 
gravel,  was  either  vomited  or  passed  from  the  bowel  or  discharged  from  the  navel. 
The  patient  died  apparently  of  ulceration  of  the  stomach — a  condition  continu- 
ally associated  with  hysteria.  The  kidneys  and  bladder  were  found  to  be  substan- 
tially natural.  Under  these  circumstances  perhaps  few  persons  in  the  present 
day  will  be  inclined  to  adopt  the  explanation  suggested  by  the  author  that  the 
urine  reached  the  stomach  by  a  retrograde  course  through  the  lymphatics.  The 
case  was  probably  one  of  hysterical  deception. 


ON    CERTAIN    RESULTS    OF    RENAL    CALCULI.  173 

-which  now  does  all  the  work,  and  one,  by  evil  chance,  slips  into  and 
plugs  its  outlet.  The  obstruction  which  now  results  will  cause  suppres- 
sion of  urine,  and  will,  if  not  speedily  dislodged,  be  necessarily  fatal. 

Obstruction  from  calculus  usually  occurs  either  at  the  funnel- 
shaped  mouth  of  the  ureter,  or  at  its  narrowed  exit  as  it  is  traversing 
the  coats  of  the  bladder.  If  a  calculus  be  small  enough  to  enter  the 
ureter,  it  will  generally  make  its  way  to  the  vesical  constriction.  A  case 
is  related  by  Sir  James  Paget  in  the  second  volume  of  the  ''Trans- 
actions" of  the  Clinical  Society.  A  fat  farmer,  seventy-four  years  of 
age,  passed  first  little  and  then  no  urine,  and  then  lived  through  twenty- 
two  days  of  suppression,  which  was  total,  except  that  on  the  thirteenth 
some  urine  escaped  during  sleep,  and  some  more,  pale  and  albuminous, 
was  voided  consciously,  the  total  discharge  amounting,  as  was  thought, 
to  about  a  pint.  In  the  early  days  of  the  suppression  there  was  a  total 
absence  of  constitutional  symptoms;  then  came  pain  in  the  left  loin,  a 
slight  convulsion,  frequent  twitchings,  nausea,  and  drowsiness.  The 
right  kidney  was  dilated,  its  secreting  structure  reduced  to  a  thin  shell, 
and  studded  Avith  cysts  of  various  sizes.  It  contained  half  a  pint  of 
urinary  fluid,  but  was  probably  useless  as  an  agent  of  continued  secre- 
tion. The  left  kidney  was  hypertrophied  and  gorged  with  blood,  and 
its  ureter  blocked  by  a  calculus  two  inches  above  the  vesical  orifice. 

Sir  James  Paget  attributes  the  unusual  tolerance  of  the  disease  in  this 
•case  partly  to  the  advanced  age  of  the  patient,  and  the  attendant  slowness 
of  the  changes  of  nutrition,  and  partly  to  an  insensitive  disposition 
which  naturally  belonged  to  him. 

The  smallnessof  a  stone,  which  will  cause  fatal  suppression  in  travers- 
ing the  sole  acting  ureter,  and  the  comparative  ease  with  Avhich  after 
death  it  can  often  be  displaced,  may  be  a  matter  of  surprise.  One  may 
be  disappointed  that  the  trifling  amount  of  force  necessary  for  its  expul- 
sion was  not  by  some  happy  chance  directed  upon  it  during  life.  A  stone 
under  the  weight  of  two  grains  has  been  known  to  be  thus  fatal. 

Calculous  suppression  of  urine  associated  so  often  with  antecedent 
chronic  changes  and  with  the  uric  acid  diathesis,  belongs  especially  to 
the  later  periods  of  life,  and  to  the  male  sex.  The  subjects  are  often 
described  as  robust  or  corpulent.  Sir  Henry  Halford  describes  as 
"paralysis  of  the  kidney,"  a  case  almost  certainly  of  tliis  nature:  the 
patient  was  a  "very  corpulent,  robust  farmer,  of  about  fifty-five  years  of 
age."'  Sir  Henry  adds  that  all  the  patients,  five  in  number,  who  fell 
under  his  care  with  similar  symptoms  were  "fat  corpulent  men,  between 
fifty  and  sixty  years  of  age."  The  subject  of  Sir  James  Paget's  case, 
already  referred  to,  was  a  fat  farmer  seventy-four  years  of  age,  older  than 
most  thus  affected.  The  four  patients,  whose  cases  I  have  given  in  detail, 
varied  in  age  from  forty -six  to  sixty-two:  three  were  of  the  male  sex,  one 
■corpulent  to  monstrosity. 

Dr.  Eoberts  has  placed  upon  record  three  cases  of  fatal  calculous  sup- 
]>ression,  in  all  of  which  the  subjects  were  of  the  male  sex  and  of  ages  be- 
tween forty  and  sixty-seven.  Tlie  late  Mr.  Nuneley,  of  Leeds,  recorded 
in  the  "Pathological  Transactions,"  vol.  xi.  p.  145,  an  instance  of  su])- 
pression  in  a  woman,  whose  age  was  thirty-three,  calculi  being  found 
after  death  in  both  kidneys,  but  in  both  sex  and  age  this  occurrence  was 
somewhat  exceptional.  I  may  mention  as  unusual  in  age  and  sex  the  case 
of  a  girl  of  seventeen,  under  my  care  as  a  hospital  patient,  in  whom  total 

'  Essays  and  Orations,  p.  31. 


174-  ON    CERTAIN    RESULTS    OF    RENAL    CALCULI. 

sui»[)re3sion  of  urine  for  sixty-seven  hours  was  relieved  upon  the  passage 
of  u  ([luintity  of  uric  acid.  I  have  never  ascertained  tlie  existence  of 
calculous  su[)pression  in  childhood,  though  a  ease  is  mentioned  in  the 
chapter  on  suppression  in  which  it  was  jiresumed  to  liave  existed. 

The  course  of  the  disease  may  be  sufficiently  gathered  from  the  fore- 
going instances.  An  elderly,  but  apparently  healthy  man,  who  perhaps 
has  at  some  former  time  had  symptoms  of  gravel,  fiiuls,  to  his  surprise, 
that  he  no  longer  needs  to  pass  water.  The  cessation  may  take  place  in 
connection  with  an  attack  of  sharp  pain,  indicative  of  a  moving  stone, 
or  it  may  occur  without  warning. 

For  a  time  t)ie  patient  seems  little  the  worse.  He  is  either  entirely 
free  from  local  uneasiness,  or  he  has  merely  a  dull  pain  or  sense  of  weight 
in  the  loins,  which  does  not  trouble  him  much.  His  appetite  is  good, 
liis  general  sensations  are  those  of  health,  and  at  first  little  notice  may  be 
taken  of  the  sensation.  Presently  the  unusual  nature  of  the  occurrence, 
rather  than  any  feeling  of  illness,  causes  him  to  seek  medical  advice.  A 
catheter  is  ]iassed,  and  the  bladder  found  to  be  empty.  The  urine  may 
remain  totally  absent,  or  small  quantities  from  time,  or  now  and  then 
something  approaching  the  amount  of  a  natural  urination,  may  be  dis- 
charged. TJie  urine,  sometimes  albuminous,  is  pale,  of  low  specific 
gravity,  and  wanting  in  urea.  According  to  the  father  of  medicine,* 
"persons  affected  Avith  calculus  have  very  limpid  urine."  This  is  par- 
ticularly the  case  when  the  renal  outlet  is  obstructed.  It  has  been  else- 
where explained  that  there  is  a  direct  relation  between  poverty  of  urine 
and  obstruction  of  the  renal  outlet.  The  longer  uraemia  is  postponed, 
the  greater  the  chance  that  the  stone,  should  it  be  "  viable,"  may  com- 
plete its  ]ierilous  course  and  allow  the  kidney  to  resume  its  functions. 
This  it  will  do  with  extraordinary  activity  on  removal  of  the  obstacle. 
Should  the  obstruction  fail  to  be  removed,  symptoms  of  uragmia  will 
gradually  appear,  and  ultimately  prove  fatal,  the  period  at  which  this 
result  happens  being  very  variable,  depending  much  upon  whether  the 
suppression  be  complete  or  incomplete.  In  tlie  case  presumably  of  cal- 
culous obstruction  related  by  Sir  H.  Halford,  of  which  he  says  that  the 
others  he  saw  were  exact  copies,  the  jiatient  died  in  a  state  of  stu- 
pefaction on  the  fourth  day.  The  lady  whom  I  saw  with  Mr.  Tatham, 
in  whom  the  obstruction  was  complete,  died  on  the  fifth  day;  the  man 
seen  with  Mr.  Keen,  in  whom  it  was  likewise  complete,  died  at  the  end 
of  the  sixth.  Dr.  Koberts  relates  a  case  in  which  death  occurred  on  the 
sixth  day,  of  complete  suppression,  but  from  the  a<|ueous  character  of 
the  urine  there  was  reason  to  believe  that  some  obstruction  had  existed 
for  a  longer  period.  In  two  other  examples  which  the  same  physician 
was  able  to  pursue  to  post-mortem  examination,  death  occurred  on  the 
tenth  day  of  suppression,  which  in  each  case  was  so  far  incomplete  that 
in  one  fifty-four  ounces  (divided  over  three  days),  and  in  the  other  two 
ounces,  of  urine  were  ])assed.  Dr.  Bagshawe's  patient  died  likewise  on 
the  tenth  day,  and  in  liim  also  the  period  of  suppression  was  interrupted 
by  the  passage  on  one  occasion  of  a  small  quantity  of  urine.  Eichardson 
died  on  the  eleventh  day;  with  him  the  sujipression  was  so  far  inclom- 
pete  that  small  quantities  of  urine,  generally  two  or  three  ounces,  were 
passed  on  seven  of  the  eleven  days.  The  woman  under  the  late  Mr. 
Nunneley  survived  twelve  days  of  suppression,  uninterrupted  so  far  as 
was  known;  while  the  Hampshire  farmer,  under  Mr.  Paget,  endured  for 

'  Hippocrate?,  On  Airs,  Waters,  and  Places,  chap.  ix. 


ON    CERTAIX    RESULTS    OF    RENAL    CALCULI.  175- 

twenty-two  days  suppression,  which  was  intersected  by  the  passage  dur- 
ing one  night,  near  the  middle  of  the  period,  of  about  a  pint  of  urine.  It 
thus  appears  tiiat,  poor  as  the  secretion  is  wliich  is  yielded  against  pres- 
sure, and  small  as  it  may  be  in  amount,  it  generally  may  be  reckoned, 
upon  to  prolong  life.  It  is  possible  that  in  many  cases  of  incomplete 
obstruction  more  urine  has  escaped  than  has  been  observed.  The  results 
of  obstruction  may,  however,  ensue,  though  a  considerable  quantity  of 
the  pale  urine  in  question  has  been  voided.  Dr.  Roberts  mentions  a 
case  almost  certainly  of  calculous  blocking,  fatal  on  tlie  fifteenth  day  by 
uraemia,  in  which  a  daily  average  of  two  pints  of  urine — pale  and  of  a 
specific  gravity  of  1006 — was  discharged  throughout.  The  explanatioi\ 
of  the  fact  lies  in  the  small  proportion  of  excrenientitious  matter  which 
the  urine  in  these  circumstances  contains. 

Unless  the  obstruction  be  overcome,  the  constitutional  signs  of 
uraemia  will  inevitably  appear  sooner  or  later,  though  they  are  seldom 
prominent  until  within  a  short  time,  a  few  days  at  most,  of  death. 
Once  evident  their  course  is  rapid.  The  functions  of  the  stomach  are 
among  the  first  to  suffer,  as  shown  by  loss  of  ai)petite,  nausea,  and  occa- 
sional rather  than  continued  vomiting.  Sometimes  there  is  much 
flatulence.  Failure  of  muscular  power  early  occurs  and  increases  with  the 
uraemia.  Lassitude  and  debility  are  succeeded  by  embarrassment  of 
breathing,  which  becomes  hurried  or  slow,  panting,  and  laborious,  prob- 
ably chiefly  in  consequence  of  weakness  of  the  muscles  of  respiration. 
Finally  the  heart  shares  the  change,  the  pulse  becomes  weak,  then  slow, 
irregular,  or  intermittent,  and  at  last  in  a  large  proportion  of  cases 
death  occurs  from  asthenia,  the  ventricles  after  death  being  found  to  be 
totally  uncontracted.  The  asthenic  state  of  the  heart  may  determine  the 
manner  of  dissolution,  which  often  takes  place  suddenly,  perhaps  upon 
a  change  of  posture,  or  while  the  patient  is  sitting  uj),  without  any 
premonitory  disturbance  of  breathing  or  of  the  mental  faculties,  death 
being  immediately  due  to  an  abrupt  failure  of  the  powers  of  circulation. 

Before  muscular  failure  has  reached  its  climax  there  are  other  results 
of  blood-poisoning,  the  most  constant  of  which  are  muscular  twitchings, 
which  occur  sometimes  almost  all  over  the  body.  These  appear  to  be 
generally,  though  not  always,  present  in  advanced  uraemia  from  this 
cause.  General  convulsion  occurs  with  comparative  infrequency.  The 
tongue,  first  moist  and  tremulous,  becomes  coated,  then  brown  and  dry. 
The  functions  of  the  bowels  are  but  little  affected.  Constipation  is  some- 
times present  early  in  the  attack.  There  is  seldom  diarrhoea  unless  due 
to  medicine.  Latterly  the  motions  are  often  dark  and  peculiarly  offen- 
sive. The  skin  is  clammy  and  moist,  sometimes  there  is  much  sweating, 
seldom  of  the  distinctly  urinous  character  occasionally  observed  in  other 
diseases  of  the  urinary  organs,  more  especially  with  retention.  The  skin 
is  noticeably  cool,  aiul  to  the  thermometer  slightly  sub-normal  (9G'  or 
97°).  There  is  a  remarkable  absence  of  dropsy.  Notwithstanding  that 
five  or  six  days  may  have  passed  but  not  a  drop  of  urine,  or  two  or  three 
weeks  with  only  as  many  urinations,  the  only  oidema  observed,  and 
even  that  is  exceptional,  may  be  a  slight  puffiness  about  the  face.  The 
patient  is  sometimes  drowsy,  in  other  cases  want  of  sleep  is  experienced, 
he  is  often  restless  and  sleeps  fitfully,  with  sudden  star  tings,  and  semi- 
convulsive  disturbance.  Low  delirium  sometimes  occurs,  but,  as  a  rule, 
is  not  a  prominent  symptom.  The  pupils  are  contracted  towards  the 
end,  sometimes  to  mere  points.  In  some  cases  coma  supervenes  at  last. 
but  far  less  often  than   in  uraemia  from  other  causes.     In  suppression. 


176  OK    CERTAIN    RESULTS    OF    RENAL    CALCULI. 

from  calculus,  the  tendency  to  asthenia  is  always  marked,  and  generally 
^ives  its  character  to  the  closing  scene. 

The  preceding  account  has  been  of  necessity  founded  upon  cases 
which  have  received  the  elucidation  of  a  post-mortem  examination, 
but  it  is  not  to  be  supposed  ti)at  the  disorder  is  always  fatal,  though  the 
mechanical  disablement  of  both  kidneys  must  always  involve  mortal 
peril. 

Insanity  axd  Epilepsy  ix  Coxxection  with  Rexal  Calculi. 

The  numerous  and  important  nervous  relations  of  tlie  kidney  have 
Toeen  elsewhere  adverted  to,  and  it  has  been  sliown  that  neuralgia,  some- 
times of  extreme  severity,  is  apt  to  affect  certain  branches  of  the  lumbar 
plexus  in  connection  with  the  irritation  of  a  renal  stone.  Remote  ner- 
vous disturbances,  of  the  kind  ordinarily  called  reflex,  may  also  have 
their  origin  in  the  same  irritant.  Epilepsy  is  known  to  occur  occasion- 
4illy  in  connection  with  renal  calculi,  more  especially  when  their  move- 
ment, as  in  entering  or  traversing  the  ureter,  gives  rise  to  severe  pain. 
It  would  also  seem  that  there  is  a  concurrence,  too  frequent  to  be  acci- 
<lental,  between  renal  calculus  and  certain  forms  of  mental  derangement. 
Among  thirty-three  cases  from  the  hospital  books  in  which  calculi 
were  found  in  one  or  both  kidneys,  were  two  of  epilepsy  with  loss  of  in- 
tellect— one  of  chronic  lunacy,  and  one  of  dementia,  considered  to  be 
senile,  the  patient  being  eighty-eight,  succeeded  by  mania.  Besides 
these  there  were  four  cases  of  cerebral  disease,  probably  unconnected  with 
<;alculi,  comprising  softening,  coagulation  in  the  arteries,  and  meningitis. 
Counting  only  the  demented  epileptics  and  the  lunatics,  we  still  have  a 
larger  share  of  mental  disease  than  usually  belongs  to  thirty-three  fatal 
cases  in  St.  George's  Hospital.  It  will  be  remembered  that  Robert  Hall, 
whose  sufferings  in  connection  with  a  renal  calculus  have  been  elsewhere 
described,  was  twice  insane;  stones  of  cystine  obtained  from  the  kidney 
of  a  lunatic  have  been  referred  to  (page  150),  and  I  may  add  the  instance 
of  a  large  collection  of  stones  of  triple  phosphate,  for  which  I  have  to 
thank  my  colleague  Mr.  Thomas  Smith,  which  were  obtained  from  a 
similar  source. 


OHAPTEE  XIY. 

ON  THE  TREATMEN^l^  OF  STONE  IN  THE  KIDNEY. 

Mitigation. 

Before  discussing  modes  of  treatment  which  aim  at  cure,  and  are  at 
best  so  perilous  or  so  protracted  that  they  are  never  likely  to  be  otherwise 
than  excejotional  in  their  use,  something  may  be  said  with  regard  to  al- 
leviation. To  this  end  nature  does  much,  and  art  can  do  something. 
The  kidneys  are  comparatively  tolerant  of  stones  ;  renal  calculi,  when 
quite  immovable,  are  often  as  completely  latent  ;  and  we  may  truly  say, 
for  the  consolation  of  those  who  have  them,  that  they  are  more  often  a 
source  of  inconvenience  than  of  danger. 

Much  may  depend  upon  a  prudent  regulation  of  bodily  movement. 
The  patient  should  avoid  whatever  causes  pain  or  bleeding,  not  only 
for  the  sake  of  his  present  comfort,  but  to  keep  off  pyelitis  and  en- 
courage the  dormancy  of  the  stone.  Jolting  is  obviously  to  be  guarded 
against,  and  tremulous  or  vibratory  movements  are  often  not  less  injuri- 
ous. To  those  who  cannot  avoid  rough  carriage  travelling  by  road  or 
railway  the  evil  may  be  mitigated  by  the  use  of  an  air-cushion  as  a  seat. 
This  I  first  learned  from  a  surgeon  who  has  been  already  alluded  to  as  an 
extreme  sufferer  from  renal  calculus.  He  could  scarcely  endure  the 
jolting  and  vibration  of  his  carriage,  until  he  found  that  by  this  means 
the  movements  could  be  equalized  and  the  tremor  deadened.  Riding  on 
horse-back  is  seldom  safe.  Of  all  exercise,  walking  is  the  best,  and  is 
often  not  only  bearable,  but  advantageous  from  its  influence  upon  the 
general  health.  The  intelligent  springs  of  the  lower  extremity  are 
smoother  than  the  finest  contrivances  of  the  coach-builder.  The  gentle- 
man to  whom  I  have  referred,  though  seldom  failing  to  suffer  from  other 
kinds  of  locomotion,  could  walk  twenty  miles  a  day  in  Switzerland  with 
much  benefit  and  little  inconvenience.  A  false  step,  however — missing, 
for  example,  the  edge  of  the  pavement,  and  descending  for  an  unexpected 
three  inches — would  cause  a  paroxysm  of  pain,  and  was  instinctively 
guarded  against.  Violent  muscular  efforts  of  every  kind  must  be  avoided, 
especially  such  as  cause  tension  of  the  abdominal  muscles.  I  have  often 
known  a  severe  attack  of  hemorrhage  to  be  brought  on  by  the  lifting  of 
heavy  weights,  or  the  effort  of  jiulling,  as  at  railway  signal  levers,  and 
have  done  good  by  advising  those  actively  employed  to  change  their  call- 
ings for  sedentary  ones. 

Patients  with  renal  calculus,  or  indeed  with  calculous  disorders  of  any 
kind,  may  easily  be  too  sparing  of  water,  tlie  general  solvent  and  antago- 
nist of  concretion.  It  is  commonly  advisable  that  this  should  be  soft,  as 
rain  water,  distilled  Avater,  or  Malvern  water,  since  salts  of  lime,  even  if 
they  have  not  formed  the  centre,  are  seldom  altogether  absent  from  the 
xDuter  parts  of  stones  which  have  acquired  any  considerable  size.  Alcoholic 
12 


178        ON  THE  TREATMENT  OF  STONE  IN  THE  KIDNEY. 

drinks  are  oest  avoided ;  the  pain  of  renal  calculus  is  often  decidedly  ag- 
gravated by  them. 

To  such  general  rules  it  will  be  necessary  to  add  others  which  are 
called  for  by  the  diathesis.  These,  which  have  already  been  discussed, 
will  vary  with  the  nature  of  tlie  concretion,  and  be  indicated,  for  the 
most  part,  by  the  Jiabitual  character  of  the  urine.  For  uric  acid,  pure 
diet,  pure  air,  exercise,  and  potash  or  litliia  water  ;  for  oxalate  of 
lime,  nitromuriatic  acid  and  vegetable  bitters — remedies  which  are 
equally  called  for,  and  to  which  strychnia  and  otlier  tonics  may  be  super- 
added should  the  urine  display  a  marked  excess  of  earthy  salts,  and  which 
must  be  further  enforced  should  the  secretion  be  alkaline  from  fixed  alkali, 
and  phosphates  be  deposited. 

The  pain  of  renal  calculus,  varying  almost  infinitely  in  amount,  calls 
for  a  large  variation  of  treatment.  It  may  much  depend  upon  move- 
ment, the  regulation  of  which  has  already  been  discussed.  When  the 
attacks  are  intermitting  and  of  the  neuralgic  type,  they  are  often  much 
influenced  by  the  general  health,  and  kept  off  by  fresh  air,  quinine,  and 
strychnia.  When  severe,  anodynes  must  be  used,  the  best  of  all  being 
morphia,  or  morphia  and  atropine  together,  injected  under  the  skin. 
Prout  found  the  burning  sensation  sometimes  produced  by  calculi  of  ox- 
alate of  lime  and  the  phosphates  to  be  relieved  by  the  application  of 
l^ounded  ice  to  the  region  of  the  kidney. 

Patients  need  no  medical  sanction  to  have  recourse  to  quack  narcotics 
with  seductive  names,  which  are  as  a  rule  less  effective  and  more  dis- 
turbing to  the  general  health  than  the  subcutaneous  use  of  the  alkaloids 
which  have  been  mentioned.  Sometimes  the  pain  in  its  neuralgic  form 
in  the  loin  or  along  the  ureter  is  so  agonizing  that  the  j^atient  is  driven 
to  the  inhalation  of  chloroform.  I  have  known  a  gentleman  thus  suffering 
to  go  to  bed  habitually  with  a  bottle  of  chloroform  under  his  pillow,  and 
to  inhale  it  frequently  to  the  verge  of  unconsciousness — a  dangerous  com- 
fort, one  seldom  to  be  preferred  to  the  subcutaneous  injection  of  opiates. 
Local  anodynes,  plasters  of  opium  or  belladonna  upon  the  loins,  are  of 
trifling  service,  and  counter-irritants  of  none.  T  have  known  the  periodic 
pain  of  renal  calculus  to  be  as  regularly  relieved  by  a  full  dose  of  alkali, 
notwithstanding  that  the  duration  and  presumed  character  of  the  stone 
were  such  as  to  put  any  solvent  action  out  of  the  question. 

For  the  hemorrhage  which  a  renal  calculus  causes,  rest  is  the  best 
remedy.  Loss  of  blood  from  this  cause  is  never  so  profuse  as,  like  the 
hajmorrhage  from  malignant  disease,  to  be  a  source  of  immediate  dan- 
ger. Even  when  considerable  it  will  generally  cease  after  a  few  days,  or 
less,  of  quiet.  When  patients  become  blanched  by  this  means,  as  they 
sometimes  do,  it  is  from  the  frequent  provocation  rather  than  the  profu- 
sion of  the  bleeding.  When  in  such  cases  styptics  are  called  for,  recourse 
may  be  had  to  ergot,  iron-alum,  tannate  of  iron,  gallic  acid,  or  acetate  of 
lead  with  opium — the  last  remedy  not  the  least  effective,  though  the  least 
suited  for  frequent  use.  Drugs,  however,  are  seldom  needed  where  rest 
can  be  obtained. 

Pyelitis  from  stone  is  very  indirectly  under  our  control.  In  the 
slighter  forms,  where  there  is  no  purulent  accumulation,  but  only  a  slight 
discharge  connected  with  the  immediate  irritation  of  a  movable  calculus, 
rest  will  do  much.  When  the  outlet  has  become  narrowed,  and  possibly 
the  stone  impacted,  so  that,  as  often  happens,  matter  collects,  a  super- 
fluity only  making  its  way  through  the  difficult  exit,  the  continual  irrita- 
tion of  the  retained  matter  is  apt  to  make  the  condition  perpetual.     The 


ON   THE  TREATMENT    OF  STONE    IN   THE  KIDNEY.  179 

natural  remedy,  a  free  opening,  is  within  the  reach  of  practical  surgery, 
and  may  be  associated  with  the  removal  of  tlie  stone.  Sometimes  the 
disease  will  wear  itself  out,  leaving  the  kidney  as  a  shell  closely  fitted 
upon  the  stone,  and  sometimes  it  will  wear  out  the  patient  by  means 
of  hectic  or  lardaceous  change,  danger  of  either  calling  for  tonic  treat- 
ment. 

It  has  occurred  to  me  that  the  curative  efforts  of  nature  might  be 
hastened  in  suitable  cases  of  this  kind  by  external  pressure,  whereby  ac- 
cumulation in  the  cyst  would  be  prevented,  and  its  closure  and  obsoles- 
cence invited. 

Counter-irritants  have  had  their  day.  Sir  B.  Brodie'  used  setons  and 
issues  upon  the  loins  in  cases  where  renal  suppuration  had  ensued  upon  a 
calculus,  and  did  not  doubt  that  such  measures  were  sometimes  emi- 
nently useful;  the  advantage,  however,  of  thus  adding  one  injury  to  an- 
other may  well  be  questioned. 

The  definite  symptoms  which  accompany  the  descent  of  a  renal  cal- 
culus— a  fit  of  the  gavel,  as  it  is  often  termed — may  require  measures  to 
be  energetically  directed  towards  the  removal  of  irritation,  the  relaxation 
of  spasm,  and  the  relief  of  pain.  A  dose  of  calomel,  or  of  some  other 
rapid  aperient,  may  be  followed  by  copious  injections  of  warm  water  into 
the  bowel,  which,  if  the  left  kidney  be  affected,  will  exert  their  emollient 
action  in  its  immediate  vicinity.  Awaiting  the  action  of  the  aperient, 
the  patient  may  be  placed  in  a  warm  bath,  or  hip  bath,  or  less  effectively 
treated  by  hot  poultices  or  fomentations.  Opiates,  of  which  none  are 
so  suitable  as  morphia  subcutaneously,  may  be  used  at  once  if  the  pain 
be  severe.  Sometimes  the  anguish  is  such  that  the  inhalation  of  chloro- 
form is  called  for.  The  free  drinking  of  diluents,  where  permitted  by 
the  state  of  the  stomach,  will  increase  tJie  urine,  render  it  less  irritating, 
and  facilitate  the  passage  of  the  stone.  Alkalies  may  be  liberally  super- 
added if  the  secretion  be,  as  it  often  is,  highly  acid. 

Supression  occurs,  as  has  been  already  explained,  when  either  both 
kidneys,  in  pelvis  or  ureter,  are  simultaneously  obstructed,  or,  one  kid- 
ney having  been  disabled  previously,  a  stone  closes  the  outlet  of  the 
other.  The  treatment  of  this  perilous  state  is  rendered  uncertain  by  the 
difficulty  of  ascertaining  the  precise  state  of  the  obstruction.  Where  this 
condition  has  proved  fatal,  the  nature  of  the  obstacle  is  sometimes  dis- 
covered to  be  such  as  to  have  conceivably  admitted  of  mechanical  relief. 
Not  seldom  the  obstruction  is  a  conical  stone,  worn  to  fit  the  outlet  of 
the  pelvis,  lying,  like  a  bullet  in  a  valve,  without  impaction,  maintaining 
its  place  and  the  obstruction  chiefly  by  its  weight.  In  such  a  case,  if  the 
body  were  inverted,  as  put  in  practice  long  ago  by  the  late  Sir  James 
Simpson,^  the  fatal  adaptation  might  possibly  be  deranged;  but  the 
relief  at  best  would  be  but  temporary,  since  there  would  be  nothing 
to  prevent  the  stone  falling  back  into  the  same  position. 

Other  cases  occur  in  which  retention  has  proved  fatal  when  the  stone 
has  traversed  the  whole  of  the  ureter  and  lodged  at  its  vesical  exit, 
where  the  canal  is  at  its  narrowest.  It  sometimes  inspires  a  feeling 
akin  to  remorse  to  find  how  little  would  have  sufficed  to  have  cleared 
the  channel  and  cured  the  patient.  The  merest  touch  has  been  enough 
after  death  to  throw  into  the  bladder  a  stone,  the  last  stage  of  whose 


'  On  the  Diseases  of  the  Urinary  Organs,  edit.  4,  p.  256. 
*  EdiJi.  Medical  Journal,  1885,  p.  76. 


180         ON  THE  TREATMENT  OF  STONE  IN  THE  KIDNEY. 

journey  has  been  thus  fatally  delayed.  The  vesical  ends  of  the  ureter 
are  not  within  the  reach  of  external  manipulation  ;  but  should  the 
stone,  as  sometimes  happens,  be  exposed  to  tlie  vesical  cavity,  the 
cautious  use  of  a  sound  might  occasion  its  displacement. 

External  manipulation  of  the  renal  region,  aiul  of  as  much  of  the 
course  of  the  ureter  as  is  open  to  external  pressure,  has  been  recommended  ; 
and  Dr.  Roberts  found  in  two  cases  a  transient  flow  of  urine  to  follow 
such  measures.  "Walking,  if  necessary  with  support,  change  of 
posture  of  various  kinds,  and  blows  upon  the  sacrum  have  been  sug- 
gested. 

Diuretics  are  sometimes  of  use.  Of  these,  digitalis,  liberally  though 
watchfully  given,  promises  best.  Mr.  Brown,'  of  Haverfordwest,  pub- 
lished some  remarkable  cases  of  this  nature  which  Avere  relieved  by  the 
external  application  of  this  drug.  Reapplied  a  poultice  to  the  abdomen, 
made  when  tlie  fresh  leaves  could  be  got,  by  bruising  them  with  boiling 
water;  or  failing  these,  by  mixing  an  ounce  of  the  tincture  with  a  linseed 
poultice.  The  application  was  continued  until  the  pulse  was  decidedly 
reduced  in  rate,  a  matter  generally  of  some  hours.  A  discharge  of 
urine  generally,  in  his  cases,  accompanied  tlie  fall  in  the  pulse,  and  he 
describes  the  abundance  of  the  flow  in  graphic  terms.  In  an  instance 
where,  as  he  thinks,  the  remedy  was  too  long  persisted  in,  the  suppression 
was  superseded  by  an  alarming  diuresis  at  the  rate  of  eight  chamber- 
vessels  full  in  six  hours,  under  which  the  patient  sank.  I  cannot  adduce 
my  own  experience  in  warrant  of  such  an  extreme  result,  but  I  have 
known  small  stones  to  be  discharged  and  suppression  terminated  under 
the  influence  of  this  remedy  applied  externally  and  iiiternally,  and  can- 
not doubt  that  it  is  more  effective  than  any  other  we  know  of. 

Terebinthinate  and  other  stimulating  diuretics  have  been  used  some- 
times with  apparent  advantage,  but  there  is  no  such  evidence  in  their 
favor  as  warrants  digitalis. 

When  all  other  expedients  have  been  exhausted,  and  so  much  time 
has  passed  without  escape  of  urine  as  to  leave  little  hope  of  natural  re- 
lief, surgery  offers  a  chance  of  rescue.  Behind  the  obstruction  the  pel- 
vis is  necessarily  distended,  and  would  offer  a  fair  mark  to  the  point  of 
an  aspirator.  This  instrument  can  in  ordinary  circumstances  be  directed 
upon  the  kidney  without  risk;  and  it  is  possible  that,  with  care,  a  pelvis 
distended  with  urine  might  be  safely  tapped  with  it,  a  present  exit  pro- 
vided, and  an  opening  left  which  might  be  available  for  future  proceed- 
ings. The  chief  difficulty,  as  I  have  ascertained  on  the  dead  body,  is  to 
gauge  the  depth.  Should  the  distended  pelvis  be  transfixed,  it  is  not 
impossible  that  urine  might  be  extravasated  into  the  peritoneum.  The 
safest  and  surest  plan  would  probably  bo»  to  dissect  from  the  loin,  and 
open  the  pelvis  as  in  renal  lithotomy,  with  the  incidental  possibility  of  re- 
moving the  stone,  as  well  as  relieving  the  suppression.  I  may  refer  to  a 
case  in  which  this  operation  was  designed,  though  its  performance  was 
antici])ated  by  the  death  of  the  patient.  It  must  be  a  matter  of  nice 
judgment  to  time  the  operation — not  until  all  chance  of  relief  by  dis- 
charge of  the  stone  is  over,  and  before  there  be  any  such  constitutional 
results  of  suppression  as  to  make  it  unlikely  that  the  patient  should 
survive  any  operative  procedure. 


"'On  the  External  Use  of  Digitalis  in  Suppression  of  Urine,"  Medical  Times 
and  Gazette,  1868,  p.  86. 


ON    THK    TREATMENT    OF    STONE    IN    THE    KIDNEY.  181 

Rexal  Lithotomy,  and  Excision  of  the  Kidney  for  Stone. 

Renal  calculi  have  been  assailed  by  two  methods:  excision  of  the  stone 
with  or  without  the  kidney,  and  solution;  solution  may  be  put  aside  for 
the  present  as  of  little  practical  issue,  and  the  first  consideration  given  to 
renal  lithotomy. 

It  has  been  shown  by  what  various  channels  renal  stones,  if  they  be 
small,  may  escape  from  the  body,  and  it  has  often  happened  that, 
when  their  course  has  been  toward  the  surface,  their  efforts  at  escape 
have  been  crowned  by  their  artificial  removal  from  sinuses  and  super- 
ficial aljscesses.  The  cautious  surgery  of  nature  is  suri'ounded  by  safe- 
guards which  rarely  attend  tlie  rougher  operations  of  art. 

When  nature  has  thus  shown  "the  way,  calculi  of  considerable  size 
have  been  extracted. 

Mr.  Annandale'  successfully  drew  a  branched  stone  weighing  72  grains, 
which,  no  doubt,  lay  in  the  pelvis  of  the  kidney,  from  the  bottom  of 
a  lumbar  sinus  three  inches  in  depth;  and  many  other  instances  are 
known  in  which  small  stones  have  been  taken  from  near  the  surface,  or 
have  effected  their  escape  without  extraneous  aid. 

Surgery,  long  limited  to  thus  assisting  nature,  has  of  late  years  taken 
the  initiative,  with  the  result  of  showing  that  renal  lithotomy  is  possible 
without  any  help  or  guidance  on  her  part.  The  feasibility  of  this  opera- 
tion is  so  important  a  question  that  I  shall  briefly  review  the  existing  ex- 
perience of  it,  as  far  as  it  has  come  to  my  knowledge:  it  is  probable  that, 
as  a  record  of  fruitless  attempts  and  fatal  performances,  the  list  may  be 
incomplete,  but  it  is  to  be  presumed  that  no  successful  extraction  of  a 
stone  from  the  kidney  has  escaped  notice. 

The  cutting  out  of  renal  calculus  appears  to  have  occupied  the 
thoughts  of  snrgeons  from  remote  times,  and  even  to  have  been  once 
successfully  accomplished  at  a  comparatively  early  date  with  or  without 
the  aid  of  a  natural  fistula. 

I  exclude  as  beside  the  question,  the  archer  referred  to  in  Mezeray's 
"•History  of  France"  as  of  Baguelet,  and  of  the  time  of^Louis  XII., 
who  is  there  stated  to  have  undergone  the  removal  of  a  stone  from  "  the 
kidneys"  instead  of  the  execution  of  a  sentence  of  death  which  he  had 
incurred.^  Mezeray  gives  no  authority,  but  the  story  is  to  be  traced  to 
Ambrose  Pare,  who,  Avriting  in  the  year  1579,  relates  it  as  follows: — ^ 

The  following  history,  taken  out  of  the  Chronicles  of  Monstrelet,  ex- 
ceeds all  admiration.  "A  certain  Franck-Archer  of  Meudon,  four 
miles  from  Paris,  was  for  robbery  condemned  to  be  hanged;  in  the  mean- 
while it  was  told  the  king  by  the  physicians  that  many  in  Paris  at  that 
time  were  troubled  with  the  stone,  and  amongst  the  rest  the  Lord  of  Bos- 
cage, and  that  it  would  be  for  the  good  of  many  if  they  might  view  and 
discern  with  their  eyes  the  parts  themselves  wherein  so  cruel  a  disease  did 
breed,  and  that  it  might  be  done  much  better  in  a  living  than  in  a  dead 
body,  and  that  they  might  make  trial  upon  the  body  of  the  Franck-Archer, 
who  had  formerly  been  troubled  with  these  pains.  The  king  granted 
their  request;  whereupon,  opening  his  body,  they  viewed  the  breath- 
ing parts,  and  satisfied  themselves  as  much  as  they  desired,  and  having 
diligently  and  exactly  restored  each  part  to  its  proper  place,  the  body, 
by  the  king's  command,  was  sewed  up  again,  and  dressed  and  cured  with 

'  Edinburgh  Medical  Journal,  July,  1869. 

^  Mezeray's  History  of  France,  published  1685.     Vol.  ii.  p.  879. 

2  Works  of  Ambrose  Pare.     Translated  by  Thomas  Johnson,  p.  668. 


182        ON  THE  TREATMENT  OF  STONE  IN  THE  KIDNEY. 

great  care.     It  came  so  to  pass  that  this  Fran ck- Archer  recovered  in  a 
few  days,  and  getting  his  pardon,  got  good  store  of  money  besides." 

The  operation  was  not  so  much  lithotomy,  either  renal  or  vesical,  as 
"vivisection,  intended  not  so  much  for  benefit  of  the  Archer  as  of  the 
Loid  of  Boscage.  The  Archer  recovered  from  the  experiment,  each  part 
liaving  been  ''diligently  and  exactly  restored  to  its  proper  place." 
AViiether  he  recovered  from  the  stone,  where  it  was,  or  whether,  indeed, 
he  had  any  disease  at  the  time  of  the  operation,  though  he  "had  for- 
merly been  troubled  Avith  these  pains,"  upon  these  points  the  narrator  is 
silent. 

The  expressive  marginal  note  belongs  to  Ambrose  Pare.  I  have 
searched  the  Chronicles  of  Monstrelet  for  the  original  story,  but  without 
success. 

Tlie  first  instance  of  the  o])eration  on  which  reliance  can  be  jilaced 
is  the  oft-quoted  one  of  Mr.  Hobson,  the  Consul  at  Venice,  from  whose 
kidney  several  stones  were  excised  by  Marchetti  of  Padua.  The  incision 
was  made  through  the  back  "into  the  body  of  the  kidney,"  from  whence 
two  or  three  small  stones  were  removed  at  the  time,  and  another  the 
size  of  a  date-stone  escaped  afterwards  by  the  fistula  which  remained. 
The  fistula  was  open  ten  years  afterwards,  and  still  discharged  urinous 
fluid;  but  for  this  the  cure  Avas  complete.  The  case  is  rej^orted  by  Mr. 
Charles  Bernard,  in  the  "Philosophical  Transactions,"  for  1696;  it  was 
drawn  up  from  the  narrative,  not  of  the  surgeon,  but  of  the  patient,  cor- 
roborated by  an  examination  of  the  sinus  ten  years  after  the  operation. 
The  story  has  detail  and  the  appearance  of  truthfulness,  and  must  claim 
belief  at  least  in  the  point  of  cliief  interest  to  the  patient,  the  cutting 
into  him  deeply  from  behind  and  extraction  of  stones  by  the  wound. 
What  guide  the  surgeon  had  may  have  been  less  vividly  recalled:  there 
may  have  been  a  previous  sinus,  though  none  is  mentioned.  Indeed,  it 
is  highly  probable  that  this  was  the  case.  Tlie  patient  himself  suggested 
the  operation,  imploring  Marchetti  "that  he  would  be  pleased  to  cut 
tiie  stone  out  of  his  kidney,"  to  which  the  surgeon  responded  by  a  course 
of  dissection  which  extended  over  two  days.  It  is  not  to  be  supposed 
that  both  patient  and  surgeon  could  have  been  thus  assured  of  the  exist- 
ence and  position  of  the  stone,  had  not  there  been  some  external  evi- 
dence of  it;  while  the  tedious  nature  of  the  operation  is  consistent  with 
the  careful  following  of  some  such  guide.  As  a  rule,  a  renal  stone  does 
not  impress  itself  distinctly  as  such  upon  its  bearer;  he  knows  that  he 
has  certain  discomforts,  but  the  cause  of  them  is  a  matter  of  infei'ence, 
"which  even  in  these  days  is  often  erroneous,  as  the  results  of  nephrotomy 
testify.  Two  hundred  years  ago  the  means  of  diagnosis  were  less,  and 
the  doubts  which  must  have  beset  such  a  case,  proportionally  greater. 

The  next  case  is  even  less  explicit;  it  is  stated  in  the  "Gentleman's 
Magazine"  for  August,  1773,  that  "Mr.  Paul,  a  surgeon  at  Stroud,  in 
Gloucestershire,  lately  extracted  from  the  kidneys  of  a  woman,  by  an  in- 
cision through  her  back,  a  rough  stone  as  large  as  a  pigeon's  egg,  and 
made  an  entire  cure."  *     Xo  further  particulars  are  known. 

For  the  origin  of  neplirolithotomy  we  must  revert  to  Marchetti,  the 
citation  of  whose  case  by  Mr.  Thomas  Smitii  and  tlie  observations  with 
■which  it  was  accompanied  appear  to  have  been  the  chief  agents  in  the 
recent  iiitroduction  of  the  0])eration,  whether  it  be  regarded  as  a  revival 
or  a  novelty. 

'  Quoted  by  Mr.  Morris,  Medical  Times  and  Gazette,  April  10th,  1880,  p.  409. 


ON   THE    TREATMENT    OF    STONE    IN   THE    KIDNEY. 


183 


Table  I. 

Cases  of  Renal  Lithotomy  2^er formed  or  attemitted,  in  which  a  Stone  was 

found. 


1.  W.  W.  Dawson, 
M.D.,  Ohio.  Op- 
eration, October 
24,  1872.  ("New 
York  Medical 
Journal,"  1873, 
p.  35.) 


I  Mr.  Callender 
Operation,  June 
23,  1873.  ("St 
Bar  tholomevv's 
Hosp.  Reports," 
vol.  ix.  p.  321.) 


3.  Mr.  Morant  Ba- 
ker. Operation, 
October  28, 1874. 
("Trans.  Med. 
Cong."  vol.  ii.  p. 
265.) 


4.  Mr.  Savory.  Op- 
eration, January 
29,  1876.  (St. 
Bartholom  e  w '  s 
Statistical  R  e  - 
port.  1876.  Pri- 
vate information 
from  Mr.  Sa- 
vory.) 


Female,  aged  50.  Recurring  attacks  of  hae- 
maturia  for  eight  years;  latterly  discharge 
of  pus  with  urine.  Tumor  in  left  renal  po- 
sition, which  extended  from  the  loin  to 
within  3  inches  of  the  umbilicus,  and  mea- 
sured four  inches  vertically.  Much  pain  in 
left  lumbar  and  iliac  regions.  Flexure  of 
left  thigh.  Increase  of  pain  and  swelling, 
with  diminution  of  discharge  of  pus. 

Exploring  trocar  introduced  into  the  tumor 
with  witlidrawal  of  pus.  Incision  made 
from  last  rib  to  crest  of  ilium,  after  the 
manner  proposed  by  T.  Smith.  Kidney  ex 
plored  and  incised  to  depth  of  ^  inch.  Calcu- 
lus removed  from  pelvis,  and  drainage-tube 
inserted.  Stone  weighed  only  20  grains;  |  of 
an  inch  long,  \  inch  broad,  composed  of 
ammonio-magnesian  phosphate. 

F.,  aged  44.  Large  oval  tumor  in  abdomen, 
extending  into  right  iliac  fossa  and  nearly 
to  umbilicus.  Colon  traced  over  its  ante- 
rior aspect.  Much  pain  in  right  side,  ex- 
tending down  thigh.  Blood  and  latterly 
pus  in  urine.     Emaciation  and  hectic. 

Incision  as  for  colotomy;  cavity  of  kidney 
laid  open  and  much  concrete  pus  removed 
Branched  calculus  removed  after  portions 
had  been  broken  from  it  with  bone-forceps. 
Stone  weighed  \\  ounce,  composed  of  li- 
thates  coated  with  phosphates. 

F.,  aged  43.  Urine  tui'bid  and  purulent.  Tu- 
mor in  right  I'enal  region,  which  was  punc- 
tured and  8  ounces  of  pus  withdrawn. 
Three  weeks  after,  incision  made  in  right 
loin  as  for  colotomy;  cyst  exposed,  opened, 
and  a  large  branched  calculus  felt,  the 
greater  part  of  which  was  removed  in  pieces 
with  difficulty — a  deeply-placed  fragment 
was  left  behind.  Patient  never  fairly  ral- 
lied f  roin  the  operation,  and  died  thi-ee  days 
afterwards.  Nopos^-?uo/7e»i.  Stone  which 
was  removed  weighed  nearly  2  ounces,  and 
consisted  almost  entirely  of  phosphate  of 
lime. 

F.,  aged  40.  Had  symptoms  of  stone  in  kid- 
ney and  abscess,  pointing  in  left  loin.  This 
incised  with  relief,  small  fistula  remaining. 

About  ten  months  afterwards  oblique  inci- 
sion made  in  loin,  guided  by  the  fistula, 
and  stone  extracted  from  pelvis  of  left  kid- 
ney. Stone  measured  \\  inch  by  \  inch. 
Consisted  of  uric  acid 


Died  of  pyaemia 
on  fifth  day 
after  opera- 
tion. 


Sank  after  oper- 
ation, and  died 
on  third  day. 


Died  three  days 
after  opera- 
tion. 


]\Iade  a  good  re- 
covery. 


184 


ON    THE    TREATMENT    OF    STONE    IN    THE    KIDNEY. 


5.  Mr.  Teale.  (Re- 
ferred to  in  Mr. 
Wheel  house's 
Address  in  Sur- 
gery, ' '  Brit.  Med 
Assoc."  1878,  p. 
45). 

6.  Mr.  Morris.  Op- 
eration, Feb.  11, 
18  8  0.  (Report 
of  Clinical  Soci- 
ety,  "Lancet," 
Oct.  30, 1880.) 


V.  Dr.  Whipham 
and  Mr.  War- 
rington Haward. 
Operation,  May 
19,1881.  ("Cli- 
nical Trans.," 
vol.  XV.  p.  117.) 


8.  Mr.  Marcus 
Beck.  Operation 
Aug.  16,  1881. 
("Clinical  Soc. 
Trans."  vol.  xv. 
p.  103.) 


9.  Mr.  Butlin.  Op- 
eration, Oct.  25, 
1881.  ("Clinical 
Trans."  vol.  xv. 
p.  113.) 


Attempt  to  remove  stone  from  the  kidney  by 
incision  through  the  loin,  but  none  found 
at  the  time  of  operation.  After  death  stone 
found  impacted  in  the  upper  part  of  the 
ureter. 


F.,  aged  19.  For  eight  years  pain  in  right 
side  with  feeling  of  sickness  or  vomiting. 
Repeated  attacks  of  hsematuria.  No  pus  in 
urine.  Lumbar  tenderness,  but  no  swell- 
ing. 

Right  kidney  exposed  through  oblique  lum- 
bar incision,  renal  substance  incised,  and 
mulberry  calculus  extracted,  weighing  31 
grains. 


A  married  woman,  aged  23.  Seven  years 
previously  had  passed,  by  the  urethra,  a 
rough  calculus  as  large  as  a  date-stone. 
Later,  much  pain  in  left  loin  increased  in 
paroxysms.  Pus,  and  sometimes  blood  in 
urine.  Tumor  felt  in  left  renal  region, 
which,  under  cliloroform,  was  ascertained 
to  extend  about  four  inches  downwards 
from  the  lower  ribs  and  about  as  far  from 
the  outer  box'der  of  the  loin  towards  the 
median  line.  Incision  made  as  for  lumbar 
colotomy,  dilated  kidney  exposed  and 
opened,  with  evacuation  of  2  ounces  of  pu- 
rulent fluid,  and  removal  of  calculus  from 
lower  part  of  cavity.  Drainage-tube  left 
in  wound.  Gradual  recovery;  a  small  si- 
nus which  remained  ultimately  healed,  and 
in  January.  1882,  patient  was  seen  in  per- 
fect health. 

Male,  age  19.  Subject  to  pains  in  back  since  Cured, 
age  of  7.  Two  j^ears  before  operation  oc- 
casional haematuria;  increased  pain,  affect- 
ing left  loin,  testicle,  and  buttock,  made 
worse  by  movement,  and  occurring  in  par- 
oxysms. Frequency  of  micturition.  Slight 
fulness  felt  in  left  loin.  Urine  free  from 
albumin;  alkaline;  contained  only  trace 
of  pus.  Kidney  exposed  by  lumbar  inci- 
sion, explored  with  a  needle,  and  stone  felt. 
Kidney  opened  and  stone  removed,  which 
was  found  to  weigh  26  grains,  and  to  be 
composed  of  uric  acid  and  phosphates. 
Wound  was  healed  by  35th  day,  and  patient 
convalescent.  Irritability  of  bladder  ceased 
after  removal  of  stone.  Small  quantity  of 
pus  still  found  in  urine.     Resumed  work. 

Male,    aged    20.     Severe    "  neuralgic "    pain  Cured, 
and  retraction  of  right  testis;  some  pain  in 
lumbar  region;  urine  contained  oxalate  of 
lime  crystals,  and  trace  of  albumin.     Kid- 
ney exposed  by  vertical  incision  along  the 


Died  a  few 
weeks  after- 
wards. 


Made  a  good  re- 
covery, sinus 
left  in  loin, 
which  did  not 
c  o  mmunicate 
with  kidney, 
but  discharged 
a  trifling 
amount  of  pus 
at  intervals. 
Patient  able  to 
work  hard  as 
a  servant. 

Cured. 


ON    THE    TREATMENT   OF    STONE    IN    THE   KIDNEY. 


185 


Operator    and   Refer- 
ence. 


Case. 


10.  Dr.  Whipham 
and  Mr.  War- 
rington Haward'. 
Operation,  Nov\ 
3,  1881.  ("Cli- 
nical Society 
Trans."  vol.  xv. 
p.  133.) 


Result. 


Sank. 


11.  Dr.  Barden 
heuer,  Cologne, 
("Medical  Rec- 
ord," Feb.  15, 
1883,  p.  40. 


12.  Mr.  Bennett 
May,  Birming- 
ham. Operation, 
Oct.  20,  1882. 
Clinical  Society, 
Feb.  9,  1883. 


border  of  the  erector  spinae,  and  a  soft 
spot  felt,  in  which  was  a  hard  body.  This, 
which  proved  to  be  a  stone,  was  exposed 
and  removed.  It  was  of  oxalate  of  lime 
and  weighed  60  grains.  The  neuralgia  of  the 
testis  ceased,  but  pus  appeared  in  the  urine 
after  the  operation,  though  there  had  been 
none  before.  This  eventually  ceased,  and 
the  patient  perfectly  recovered. 

Laundress,  aged  56.  Pain  with  micturition; 
frequent  passing  of  gravel  and  occasional 
haematuria.  Pain  in  left  flank  and  groin, 
increased  by  movement.  Urine  alkaline; 
passed  in  small  quantities;  specific  gravity 
1.006;  contained  f)us,  with  crystals  of  uric 
acid  and  of  the  phosphates.  Muscular  re- 
sistance and  fulness  in  left  loin,  but  no  dis- 
tinct tumor  felt;  in  right  loin  much  fulness, 
pain  on  pressure,  but  no  distinct  fluctua- 
tion. In  front  of  abdomen  universal  ten- 
derness. October  6,  incision  made  in  centre 
of  left  lumbar  swelling,  cavity  of  kidney 
opened,  but  no  stone  felt.  Much  pain  about 
wound,  and  discharge  from  it.  On  Nov. 
23,  wound  enlarged  and  further  explored; 
no  stone  found.  Patient  never  rallied,  but 
sank  on  the  following  day.  Post-mortem 
— Left  kidney  dilated;  pelvis  opened  into 
suppurating  cavity  behind  it,  into  which 
incision  had  been  made.  Two  or  three 
small  pieces  of  calculus,  like  pins'  heads, 
had  formed  in  calyces.  Large  branching 
calculus  in  right  kidney,  which  almost 
blocked  ureter. 

Man,  aged  27.  Portion  of  elastic  catheter  Permanent  dis- 
broken  into  bladder — consequent  cystitis  charge  of 
with  abscess  in  left  iliac  fossa,  which  pre-  urine  through 
sumably  became  connected  with  the  pelvis  the  wound  in 
of  the  left  kidney.  Five  weeks  later  rigor  loin.  Recov- 
and  suppression  of  urine  occurred.  A  ca-  ery  incomplete 
theter  brought  from  the  bladder  only  mucus  at  date  of  re- 
and  a  small  calculus.  Obstruction  of  the  port. 
right  kidney  by  calculus  diagnosed.  Inci 
sion  made  from  the  eleventh  rib  to  the  crest 
of  the  ilium.  Stone  felt  in  the  hilum.  Pel 
vis  exposed  at  bottom  of  wound,  and  stone 
as  lai'ge  as  a  bean,  with  several  smaller 
pieces,  ultimately  removed  through  an  in- 
cision in  the  commencement  of  the  ureter. 
Urine  afterwards  passed  entirely  through 
wound.  Four  days  later  ureter  cut  and  up- 
per end  fixed  in  wound,  through  which 
urine  was  permanently  discharged.  At 
date  of  report,  wound  uniting,  and  patient 
recovering,  though  feeble. 

Coal  miner,  aged  34.  Symptoms  since  six-  Wound  per- 
teen,  hasmaturia,  ropy  discharge,  pain  in  fectly  healed 
loin  increased  by  exertion.  Occasional  at-  and  recovery 
tacks  of  renal  colic;  small  stone  passed,  complete. 
Incision  from  the  loin,  stone  not  felt  with 
finger,   but  by  acupuncture.    Kidney  ap- 


186 


ON    THE    TREATMENT    OF    STONE    IN    THE    KIDNEY. 


Operator    and    Refer- 
ence. 


13.  Mr.  Berkeley 
Hill.  Operation, 
March  21,  1883. 
Private  informa- 
tion. 


Case. 


pareutly  liealthj-,  incised  vertically,  and 
stone  extracted,  which  was  3  inches  long, 
and  weighed  1  ounce.  Chiefly  phosphatic. 
Much  bleeding,  pain,  and  shock.  Subse- 
quent slight  pleurisy. 
Female,  aged  26.  For  several  years  attacks 
of  pain  in  right  hj'pochondrium  and  vom- 
iting. Fluctuating  swelling  in  loin,  from 
which  4^  ounces  of  pus  removed  by  aspira- 
tion. Cavity  of  kidney  evacuated  by  lum- 
bar incision,  and  stone  taken  out,  apparent- 
ly consisting  of  oxalate  of  lime.  It  weighed 
64  grains  and  measured  Ij  inches  in  length. 
Urine  ceased  to  escape  by  wound  16  days 
after  operation.  Wound  closed  in  31  days. 
Coexistent  urethritis  and  vaginitis. 


Result. 


Patient  in  per- 
fect health  9 
weeks  after 
operation,  ex- 
cept that  urine 
still  contained 
pus. 


14.  Peters.  1880. 
"  Berliner  Med. 
Wochenschrif  t, " 
(Referred  to  by 
Mr.  Baker,  Cli- 
nical Soc.  "Lan- 
cet," Oct.  30, 
1880.) 


Renal  Lithotrity. 

Symptoms  of  renal  calculus  were  verified  by 
the  passage  of  trocar  and  canula,  and  the 
striking  of  a  stone  in  the  kidney.  Canula 
left  in  for  some  time,  after  which  wound 
dilated  by  tents,  until  the  sinus  was  large 
enovigh  to  admit  the  finger.  Lithotrite 
,  passed,  stone  crushed  and  removed.  Sinus 
afterwards  healed.' 


Cured. 


Table  II. 
Cases  of  attemiJted  Renal  LWiotomy  iti  wJiich  no  Stone  was  found. 


Operator   and   Refer- 
ence. 


Case. 


Result. 


1.  Mr.  Durham, 
Guy's  Hospital, 
February  3, 1870. 
('*  Med.  Times," 
Feb.  12,  1870.) 


.  Professor  IM  OSes 
Gunn,  Chicago, 
April  16,  1870. 
("New  York 
MedicalJourn. , " 
1873,  vol.  xvii., 
p.  47.) 


F.,  aged  41.  Incision  along  the  edge  of  the 
erector  spinae,  from  the  pelvis  to  the  elev- 
enth rib,  hilum  of  the  kidney  reached 
with  little  difficulty,  but  no  stone  found. 
Pelvis  and  ureter  examined  on  the  outside, 
but  not  opened.  All  appeared  perfectly 
healthy.  Recovered  from  operation,  but 
not  relieved  of  pain,  hsematuria,  and  other 
symptoms  from  which  she  had  suffered. 
[For  conclusion  of  case  see  Table  IV., 
Case  1.] 

Man,  "  who  for  five  months  had  suffered  from 
symptoms  which  indicated  the  probable 
presence  of  a  renal  calculus."  Kidney  ex- 
posed fi'om  behind;  pelvis  and  commence- 
ment of  ureter  examined,  but  no  stone 
found.  Organ  seemed  shrunken  and  soft, 
but  was  not  interfered  with.  Recovered 
from  the  operation;  nausea  which  had  been 
nearly  continuous,  was  relieved,  and  pain 


Recovered  from 
the  first  opera- 
tion. 


Recovered. 


!■' 


'  See  also  Case  5  and  6  in  Table  HI. 


ON  THE  TREATMENT  OF  STONE  IN  THE  KIDNEY. 


187 


,  Mr.  Bryant, 
1870.  ("Lancet," 
July,  1870,  p.  13; 
also  August  27, 
1870,  p.  292.) 


Mr.      Bryant, 

1878.       (Private 
letter.)! 


Mr.  Golding 
Bird.  (Discus- 
sion at  Clinical 
Society,  ' '  Lan- 
cet," October  30, 
1880.) 


,  Dr.  Baxter  and 
Mr.  M  o  r  a  n  t 
Baker.  ("Trans. 
Med.  Congress," 
vol.  ii.  p.  262. 
Dec.  7,  1880.) 


Mr.  Morant 
Baker.  ("Trans. 
Med.  Congress," 
vol.  ii.  p.  264 
May  15,  1881.) 


disappeared.  These  symptoms  returned 
six  weeks  afterwards. 

Fulness  perceptible  to  hand  and  eye  in  left 
loin;  pain  down  spermatic  cord.  Pus  in 
urine.  Diagnosis  of  renal  cyst  containing 
pus.  Stone  to  be  removed  if  found.  Ob- 
lique incision  in  loin  like  that  for  colotomy. 
Kidney  fairly  exposed;  curved  trocar 
passed  through  its  cortex,  and  flow  of  pus 
ensued.  Pelvis  explored  internall3\  but  no 
stone  found.  After  death  kidney  found  to 
be  the  seat  of  tuberculous  excavation;  no 
stone  present.  Incision,  which  had  entered 
back  of  pelvis,  was  healing. 

Lady,  aged  56.  Passed  a  stone  six  years  be- 
fore, after  an  attack  of  renal  colic  on  the 
right  side.  Pain  relieved  but  not  removed; 
continued  of  a  dull  aching  character.  Pus 
in  urine.  Right  lumbar  region  incised 
down  to  kidney,  and  10  ounces  of  pus 
evacuated.  Kidney      found      "honey- 

combed," but  no  stone  discovered.  Opera- 
tion gave  relief  at  once:  pus  disappeared 
from  urine.  For  a  time  urine  passed 
through  wound,  w^hich  was  washed  out 
daily  with  iodine  water.  In  two  months 
lumbar  opening  closed,  and  patient  well. 

Intense  "renal  neuralgia,"  on  the  left  side, 
in  a  boy,  from  whose  urethra  an  impacted 
calculus  had  been  removed;  also  pain  in 
bladder.  Kidney  cut  down  and  explored, 
back  and  front,  but  no  stone  found.  Tem- 
porary relief,  then  pain  returned.  After- 
wards Mr.  Durham  cut  into  bladder,  but  no 
stone  found. 

Girl,  7  years  of  age.  Attack  of  hasmaturia 
eighteen  months  before  admission;  another 
subsequently.  Urine  became  jiurulent. 
Swelling  in  region  of  right  kidney;  much 
hectic.  Incision  made  as  for  lumbar  colot- 
omy; no  stone  found.  Drainage-tube  in- 
serted; pus  in  urine  and  hectic  continued. 
(See  Table  IV.,  Cases.) 

Boy,  aged  16  years.  Frequent  attacks  of  pain 
in  left  renal  region  for  four  years  before 
admission.  Fluctuating  tense  swelling, 
evident  during  attack  of  pain,  in  left  renal 
region;    subsiding    afterwaixls,    with    dis- 


Died  on  twenty- 
fifth  day  after 
operation,  of 
acute  perito- 
nitis, which 
supervened 
upon  chronic. 


Recovered. 


Recovered. 


Survived  opera- 
tion, but  re- 
ceived no 
benefit. 


Recovered  from 
the  operation. 


'  I  have  to  thank  Mr.  Bryant  for  giving  me  the  advantage  of  his  large  expe- 
rience, both  published  and  unpublished.  In  his  well-known  work  on  surgery 
(edit.  3,  vol.  ii.  p.  57)  are  two  cases  in  which  he  cut  from  the  loin  into  a  renal 
swelling,  evacuating  in  one  instance  3  pints,  in  the  other  a  quart,  of  pus.  In  the 
latter  the  finger  was  easily  passed  into  the  dilated  pelvis  of  the  kidney.  As  to 
the  results  of  these  operations,  one  patient  "made  a  good  recovery,"  the  other 
received  "marked  benefit."  I  have  been  informed  by  Mr.  Haffenden,  under 
whose  care  one  of  these  patients  now  is  (April  1881),  that  she  has  a  permanent 
fistula  as  the  result  of  the  operation,  through  which  what  appears  to  be  all  the 
urine  of  one  kidney  makes  its  exit.  I  have  not  included  tliese  cases  in  the  table, 
as  the  object  in  view  appears  rather  to  have  been  the  release  of  imprisoned  matter 
than  the  removal  of  stone. 


188 


ON    THE    TREATMENT    OF    STONE    IN    THE    KIDNEY. 


,     Mr. 
Lucas. 


letter,  1881.) 


charge  of  pus  with  the  urine.  Incision  as 
for  lumbar  colotomy;  dilated  kidney  ex- 
posed and  incised,  but  no  stone  found.  Pa- 
tient recovered  from  operation  with  per- 
manent fistula,  in  which  a  drainage-tube 
was  inserted. 

Clement  Man,  aged  48,  who  for  two  years  had  had 
(Prirate     haeniaturia,  and  passed  pelvic  clots.     Kid- 


ney exposed  by  an  incision  parallel  to  last 
rib,  and  felt  all  over  without  discovery  of 
stone.  The  kidney  does  not  appear  to  have 
been  opened.  The  wound  readily  healed, 
and  the  patient  left  his  bed  in  a  fortnight. 


Recovered  from 
the  operation. 


Table  III. 


Removal   of  Kidnev  for  Stone,  either   as  Sequel   to   Lithotomy  or  in- 
dependently.    Stone  2)7'esent. 


.  Simon  (Heidel 
berg).  Aug.  8 
1871.  Barker 
("  Medico-Chir. 
Trans,  ".vol.  Ixiii. 
p.  210.) 

,  Muller  (Olden- 
burg). February 
18,  1878.  Barker 
("  Medico-  Chir. 
Trans."  vol. 
Ixiv.  p.  272.) 


3.  Czerny  (Heidel- 
berg). March 
15, 1880.  Barker. 
("  Medico.-  Chir. 
Trans."  vol.  Ixiv. 
p.  278). 

4.  Barker  (London) 
July  5,  1880. 
("  Medico-Chir. 
Trans."  vol.  Ixiv. 
p.  278.) 

5.  Barker  (Lon- 
don). October  5, 
1880.  ("  Med.- 
Chir.  Trans." 
vol.  Ixiv.  p.  278 
"Lancet,"  Oct. 
30,  1880.) 


F.,  aged  30.     Symptoms  of  calculous  pyelitis  Died    on  thirty- 
for    twelve  years.     Kidney    extracted    by     first      day    of 
lumbar  incision.     Vomiting  and  abdominal     pyaemia, 
pain   afterwards.     Kidney  small,   fibrous; 
contained  calculus. 

M.,  aged  21.  Symptoms  of  calculous  pyelitis 
for  three  or  four  years.  Renal  abscess 
opened  in  September,  1877,  and  drained 
Nephrectomy  by  lumbar  incision,  when  fis- 
tula closed.  Perinephritic  abscess  after 
■wards,  which  had  to  be  drained  into  rectum 
Kidney  dilated  into  sac  with  adherent  cal- 
culi. 

M.,  aged  23.  Pain  and  haematuria  from  child- 
hood. Pain  increased  by  exercise,  Avhich 
latterly  became  imiwssible.  Nephrectomy 
by  lumbar  incision;  which  had  healed  in 
fourteen  days.  Small  calculus  in  slightly 
dilated,  but  otherwise  healthy,  kidney. 

F.,  32  years.  Renal  pain  since  childhood; 
swelling  noticed  one  montli.  Pyonephrosis 
diagnosed,  and  attributed  to  calculus.  Ne- 
phrectomy by  lumbar  incision.  Kidney 
vascular  and  dilated.  Small  calculus  in 
mouth  of  ureter. 

F.,  aged  38  pears.  Anasmic.  Pain  fifteen 
months.  Pyelitis.  Swelling  twelve  months. 
Diagnosis  between  stone  and  tubercle,  de- 
termined by  striking  stone  with  needle 
passed  through  loin.  Kidney  exposed  by 
lumbar  incision,  and  opened.  Large 
branched  stone  found,  but  only  a  portion 
extracted.  Kidney  then  enucleated  and 
tied,  after  which  it  was  found  that  stone 


Recovery  com- 
plete after 
16  months. 


Recovered. 


Death  from 

shock  in  four 
hours. 


Died  of  shock  in 
twelve  hours. 


■•* 


ON    THE    TREATMENT    OF    STONE    IN    THE    KIDNEY. 


189 


6.  Barwell  (Lon- 
don). May  5, 
1881.  ("Trans. 
Med.  Congress,'" 
vol.  ii.  p.  275.) 


7.  Dr.  Barlow  and 
Mr.  G  o  d  1  e  e. 
("Clin.  Trans." 
vol.  XV.  p.  13-i. 
July  15,  1881.) 


.  Rosenbach, 
July  24,  1881. 
"  Berliner  Klini- 
sche  Wochen- 
schrift,"  Janu- 
ary 30,  1882. 


.  Dr.  Williston 
Wright  (New 
York).  October 
14,  1882.  "  New 
York  Medical 
Journal,"  Febru- 
■ary  17,  1883. 


could  be  exti'acted.  Kidney  sacculated 
Colon  torn  in  course  of  operation, 
M.,  aged  18  years.  Swelling  in  loin,  which 
broke  and  discharged.  Urine  contained 
muco-purulent  matter,  and  afterwards 
much  pus.  On  October  18,  1880,  incision 
as  for  lumbar  colotomv ;  6  ounces  of  pus 
discharged;  sinus  left,  at  bottom  of  which 
stone  was  ultimately  felt.  May  5,  1881: 
Another  lumbar  incision  outside  sinus; 
stone  found  to  be  deeply  imbedded;  broke 
and  could  not  be  removed  Kidney  there, 
fore  ligatured  and  removed.  Many  frag 
ments  of  stone  came  away  during  operation 
and  afterwards. 
Married  woman,  aged  57.  Passed  stone 
twenty-six  years  before.  For  three  months 
pains  in  back.  Urine  thick,  milky,  and 
frequent.  Tumor  felt  in  right  side  from 
ribs  to  within  linger's  breadth  of  crest  of 
ilium,  at  lower  part  of  which  was  projec- 
tion, which  was  thought  to  be  calculus. 
Much  pus  in  urine.  Legs  oedematous  at 
times.  Stone  felt  with  needle  introduced 
through  loin.  Kidney  removed  by  inci- 
sion in  medium  line  of  abdomen.  Opera- 
tion protracted.  The  kidney,  which  had 
been  removed,  contained  several  calculi 
of  uric  acid;  it  was  almost  entirely  disor 
ganized.  Other  kidney  healthy. 
Male,  aged  43.  Frequent  attacks  of  htema 
turia  since  age  of  IS.  Passed  many  stones 
of  size  of  lentils.  Swelling  in  loin  which 
was  punctred.and  pulpy  and  chalky  matter 
let  out.  Hsematuria  recurred  after  punc 
tux-e.  Some  months  afterwards  kidney  re- 
moved by  lumbar  opening.  Found  to  con- 
tain matter  and  many  concretions  of 
phosphate  of  ammonia  and  magnesia,  the 
largest  of  which  were  of  the  size  of  cherries. 
Married  woman,  aged  34.  For  9  years,  pain 
in  right  loin.  For  4  years  urine  ammonia- 
cal  and  contained  pus  and  blood.  Pro- 
cidentia of  uterus  and  bladder  of  long-stand- 
ing, consequent  upon  labor.  Tumor  as 
large  as  fist  felt  in  right  loin,  at  inner  mar- 
gin of  which  was  nodulated  lump  as  large 
as  walnut,  thought  to  be  stone.  Kidney 
removed  by  incision  along  edge  of  rectus 
muscle.  Left  kidney  felt  through  wound 
in  normal  position.  Right  kidney  pyelitic, 
contained  phosphatic  stone  weighing  135 
grains.  Obstruction  of  bowels  after  opera- 
tion. Wound  reopened  and  abscess  found 
near  stump  of  divided  vessels  which  pressed 
on  ascending  colon.  Three  ounces  of  pus 
discharged  and  obstruction  relieved.  Ab- 
scess thought  afterwards  to  discharge  into 
bladder. 


Recovered. 
Sinus  left, 

through  which 
little  urine 
came. 


Sank  twenty- 
four  hours 
afterwards. 


Perfectly  recov- 
ered by  No- 
vember        12, 

1881. 


Recovered  from 
the  operation. 
Remained  in 
weak  health 
with  much  dis- 
charge of  pus 
with  urine. 


190 


ON    THE    TREATMENT    OF    STONE    IN    THE    KIDNEY. 


Table  IV. 

Removal   of  Kidney  for  Stone,  either  as   Sequel   to   attempted  Litliot- 
omy  or  indejjendently.     No  Stone  Present. 


Operator    and    Refer- 
ence. 


Case. 


.    Durham    (Lon-  F.,  aged  43.     Reported  as_case  of  attempted 

don).  May,  1872. 

("New        York 

Med.        Journ." 

vol.  xiv.  p.  485, 

1872.  "Brit. 

Med.        Journ." 

May,  1872.)    See 

Case  1,  Table  II. 
.   Peters        (New'M 


Result. 


lithotomy  in  Table  II.  Two  years  after  this 
operation,  patient  not  having  been  relieved 
of  pain,  hsematuria,  and  other  symptoms, 
right  kidney  removed  bj'  lumbar  incision, 
and  found  to  be  healthy.     Details  wanting 


aged  36.  Symptoms  for  nineteen  months, 


York),  May    16,      Frequency  of  micturition;  pains  in  bladder 
1872.         ("New     and  right  renal  region;  much  pus;  and  oc 
York         Med.      casional  streak  of  blood  in  urine.     Swell 
Journ."  vol.  xvi.      ing  of  right   testicle  and  spermatic  cord 
p.  473,  1872.)  Enlargement  in  position  of  right  kidney 

aspirator  withdrew  3  ounces  of  pus;  sup- 
posed fragments  of  stone  in  eye  of  trocar, 
Incision  from  lower  border  of  twelfth  rib  to 
crest  of  ilium.  Kidney  found  to  contain 
pus;  no  stone  discovered.  Thought  to  be 
useless  and  to  have  been  damaged  in  opera- 
tion— therefore  removed.  Found  to  be 
extensively  tuberculous,  as  also  were  right 
ureter,  seminal  vesicle,  and  epididymis. 
Dumrarei  c  h  e  r  M.,  aged  33.  Weak  and  anfemic.  Symptoms 
(Vienna).  Aug.  I  from  childhood,  worse  for  ten  years.  Pye- 
litis supposed  to  be  of  calculus  origin;  with 
perinephritic  abscess  on  left  side.  Neph- 
rectomy by  lumbar  incision.  Pleura 
wounded  in  course  of  operation.  Kidney 
vascular  and  dilated;  imbedded  in  dense 
inflammatory  tissue.  No  stone. 
M.,  aged  54.  Passed  calculi  twenty -six  years.  Died 
before.  Healthy  until  fourteen  years  be- 
fore. Symptoms  of  calculous  pyelitis. 
Lumbar  incision.  Kidney  difficult  to  re- 
move in  consequence  of  dense  mass  of  ad- 
herent tissue  by  which  it  was  surrounded 
Severe  haemorrhage  from  renal  veins.  Kid- 
ney enlarged  and  sacculated. 
F.,    aged    7    years.     Attack    of    hgematuria  Much 


6.  1877.  (Barker, 
"Med.  Chir. 
Trans."  vol.  Ixvi. 

p.  272.) 


,  Stock  well 
(Bath).  June  2, 
1880.  (Barker, 
"Med.  Chir. 

Trans. "vol.  Ixiv. 
p.  280.) 


,    Morant 
(London), 
ruary   22, 
("Trans. 
Congress," 
ii.    p.    262 


Baker 

Feb- 

1881. 

Med. 

vol. 

See 


Died     a     week 
afterwards. 


Sank  sixty-five 
hours  after- 
wards. 


Died  on  second 
day 


L  ten 
hours  from 
hemorrhage. 


i 


Case 
II.) 


7,     Table 


6.  Howard  Marsh 
(London).  Dec. 
1881.  ("  Clin. 
Trans,  vol.  xv. 
p.  140.) 


eighteen  months  before  admission;  another 
subsequently.  Urine  became  purulent. 
Swelling  in  region  of  right  kidney.  Much 
hectic.  December  7.  1880,  incision  as  for 
lumbar  colotomy.  No  stone  found.  On 
February  22  kidney  removed  through  place 
of  former  incision.  Kidney  scrofulous. 
Much  improvement;  but  in  July,  1881, 
urine  still  contained  pus. 
M.,  aged  58.  Pain  in  right  loin  three  years 
before  admission.  Urine  then  purulent, 
foetid,  and  passed  with  frequency.  Urine 
sometimes  nearly  clear;  discharge  reappear- 
ing with  rigors  and  paroxysm  of  pain  from 


ment. 


miprove- 


Died  with  sup- 
pression of 
urine  thirty 
hours  after- 
wards. 


OK  THE  TREATMENT  OF  STONE  IN  THE  KIDNEY. 


191 


Operator    and    Refer- 
ence. 


7.  J.  Adams  (Lon- 
don). March, 
1882.  (Private 
letter.) 


Case. 


loin  to  testis.  Pyelitis  diagnosed ;  probably 
of  calculous  origin.  Kidney  exposed  by 
lumbar  incision,  and  much  pus  let  out.  No 
stone  found.  Removal  of  kidney  attempted, 
but  only  partially  accomplished.  Right 
kidney  found  to  be  sacculated  in  conse- 
quence of  stricture  of  ureter  of  uncertain 
origin,  and  surrounded  by  adhesions.  Oppo- 
site kidney  natural. 
M.,  aged  30.  Hsematuria  for  two  years; 
latterly  constant  and  profuse.  Clots  ex- 
pelled with  difficulty.  Constant  pain  in 
right  loin;  no  increase  of  lumbar  dulness. 
Phosphates,  blood,  and  epithelium;  but  no 
casts  in  urine.  Marked  anfemia.  Incision 
in  loin;  no  stone  found.  Kidney  then  ex- 
cised— it  proved  to  be  the  seat  of  a  malig 
nant  growth. 


Result. 


Recovered  from 
i  n\  m  e  d  i  a  t  e 
effects,  but 
died  in  two 
months  from 
secondary 
growths. 


ABSTRACT   OF  TABLES. 


Number  of  persons  operated  upon  for  stone  in  kidney, 

Stone  present  in, 

Stone  not  present  in, 


35 
22 

13. 


State  of  Kidney  in  13  Cases  in  which  Stone  zvas  not  found. 

Tuberculous,  or  scrofulous, 3 

Seat  of  malignant  growth, 1 

Dilated    or    sacculated    from    pyelitis    of    uncertain 

cause,            5 

Healthy, 1 

Not  ascertained, 3 

13 


Tables  I.  and  II. 
Renal  Lithotomy  and  Lithotrity. 


Stone  Present. 

No  Stone  Present. 

Cases. 

Recov- 
ered. 

Died. 

Cases. 

Recov- 
ered. 

Died. 

Renal    Lithotomy     performed,     or    at- 
tempted, without  nephrectomy 

Renal  Lithotrity 

13 

1 

8 
1 

5 

8 

7 

1 

192 


ON  THE  TKEATMENT  OF  STONE  IN  THE  KIDNEY. 


Tables  III.  and  IT. 

Nephrectomy  for  Stone. 


Stone  Present 

No  Stone  Present 

Cases 

Recov- 
ered 

4 
1 

Died 

Cases 

Recov- 
ered 

Died 

Lumbar   nephrectomy,   in    some    cases 
immediately  preceded    by  attempted 
lithotomy 

7> 
2 

3 
1 

T 

2 

5 

Abdominal  nephrectomv 

Particulars  of  22  Operations  for  Stone  existing  in  the  Kidney,  referred 
to  in  Tables  I.  and  TIL 


Operation 


Number 
of  eases 


Stone  removed  by  lumbar  incision,  without  previous  sinus 

Stone  removed  by  lumbar  incision,  sinus  previously  ex 
isting -    ... 

Lumbar  incision,  but  stone,  which  was  in  ureter,  not 
reached 

Lumbar  incision.  No  stone  found  at  operation,  though 
minute  calculi  existed.     Large  stone  on  opposite  side 

Lithotrity  through  puncture  in  loin 

Lumbar  nephrectomy,  in  many  cases  succeeding  upon  at- 
tempted lithotomy 

Nephrectomy  through  abdomen  without  incision  in  loin. . 


23 


Recov- 
ered 


13 


Died 


I  have  annexed  in  a  condensed  form  the  particulars  of  thirty-five 
cases  in  whicli  operations  have  in  recent  times  been  performed  for  stone 
in  the  kidney,  omitting  several  of  which  the  result  is  uncertain  or  not 
fully  stated ;  tlie  catalogue,  even  if  not  complete,  may  fairly  represent 
present  experience.  First,  as  to  tiie  existence  of  the  disease  whicli  it 
was  designed  to  remove,  it  a^ipears  that  in  thirteen  of  these  cases  no 
stone  was  found,  a  proportion  of  erroneous  diagnosis  wliicli  is  certain  to 
diminish  now  that  attention  is  called  to  this  subject.  It  can  scarcely  be 
accepted  as  a  persistent  rule  that  in  a  third  of  the  instances  in  wliich  a 
renal  stone  is  confidently  diagnosed,  no  such  concretion  exists.  Did  the 
difficulty  of  diagnosis  amount  to  this,  the  feasibility  of  any  operation  for 
its  removal  with  or  without  the  kidney  would  scarcely  need  further  dis- 


'  One  of  these  cases  is  also  counted  in  Table  I.,  as  lithotomy  had  been  at- 
tempted at  an  earlier  date. 

'^  Two  of  these  cases  are  also  counted  in  Table  IL,  as  lithotomy  had  been  at- 
tempted at  an  earlier  date. 


o:h  the  tkeatment  of  stone  in  the  kidney.  193 

ciission.  But,  as  in  many  novel  enterprises,  the  early  adventurers  fell 
into  errors,  which  may  serve  as  warnings  against  their  repetition.  The 
incision  into  and  the  removal  of  the  healthy  kidney  presents  itself  in  this 
light.  With  such  facts  before  us  as  the  tables  present,  we  may  at  least  insist 
that  no  operation  for  the  relief  of  renal  calculus  be  undertaken  on  the 
evidence  of  pain  or  general  symptoms,  unless  corroborated  by  the  dis- 
charge of  blood  or  pus,  or  at  least,  as  in  Mr.  Butlin's  case,  of  crystals 
and  albumin.  The  doubt  likely  to  occur  in  future,  is  not  between  disease 
and  no  disease,  but  between  stone  and  tubercle.  The  distinctions  have 
been  detailed  elsewhere  (pp.  89,  1G4:).  With  tubercle  there  is  usually 
a  characteristic  look,  family  liistory  and  temperature,  and  often  disease 
possibly  incipient  in  the  lungs.  The  pain  is  not  acute,  nor  does  it  widely 
extend,  nor  is  it  aggravated  by  movement  or  in  paroxysms.  Hasmaturia 
is  the  exception,  cystitis  the  rule.  With  stone,  these  statements  may  be 
reversed.  By  way  of  insuring  the  diagnosis,  a  calculus  has  been  struck 
with  a  needle  inserted  behind;  this  could  scarcely  be  reckoned  upon  un- 
less, as  in  a  case  in  which  Mr.  Barker  thus  detected  a  stone,  it  presented 
a  large  surface.  Manual  explorations  by  the  rectum  may  sometimes  be 
of  use,  and  an  instance  has  been  referred  to  in  which  the  grating  of 
stones  in  the  kidney  was  felt  through  the  abdominal  wall.  It  has  been 
supposed  that  single  stones  could  be  detected  by  palpation  through  the 
integuments,  particularly  in  children  and  under  chloroform,  but  though 
a  lump  may  be  thus  discovered  in  the  renal  position,  its  nature  may  be 
doubtful.  A  stone  diagnosed  by  this  means  has,  within  my  knowledge, 
turned  out  to  be  tubercle.  As  a  rule,  the  diagnosis  of  stones  in  the  kid- 
ney rests  not  on  any  one  certain  indication,  but  on  the  concurrence  of 
a  number  each  of  which  and  all  together  may  be  mistaken.  A  some- 
what careful  balancing  of  evidence  is  often  needed,  Avhich  in  the  cases 
before  us  does  not  appear  always  to  have  found  place.  A  doubt  as  to 
the  existence  of  a  stone  must,  as  a  rule,  negative  any  operation  for  it, 
notwithstanding  that  it  is  clear  that  the  kidney  can  be  cut  into  from  be- 
hind, whether  tentatively  or  otherwise,  without  great  danger,  supposing 
that  nothing  else  is  attempted. 

Putting  aside  all  operations  founded  upon  erroneous  diagnosis,  and 
considering  only  those  undertaken  for  the  removal  of  existent  calculi,  we 
have  the  following  results: — 

The  kidney  has  been  opened  from  the  loin  for  tlie  purpose  of  remov- 
ing a  stone  from  it,  in  sixteen  cases,  in  fourteen  of  which  the  operation 
was  limited  to  lithotomy  or  lithotrity,  and  is  accordingly  detailed  in 
Table  I.;  in  two  nephrectomy  was  executed  upon  the  failure  of  the  less 
formidable  procedure,  and  the  instances  therefore  referred  to  in  Table 
III.  Of  the  sixteen  operations,  eight  were  immediately  successful;  eight 
unsuccessful ;  six  fatal.  Of  the  unsuccessful  operations,  two  were,  as 
stated,  followed  by  nephrectomy,  once  with  a  favorable,  once  with  a  fatal 
issue.  In  one  of  the  cases  of  successful  lithotomy  there  was  a  previous 
sinus;  in  seven,  none.  One  instance  is  included  in  which  tiic  stone  was 
crushed,  and  then  removed  through  a  puncture  rather  than  an  incision. 
In  two  of  the  cases  counted  as  successful,  a  sinus  was  left  at  date  of  the 
report,  one  of  which  did  not  communicate  with  the  kidney;  in  the  rest 
healing  was  complete.  Among  the  unsuccessful  cases  was  one  in  which 
the  stone  was  not  on  the  side  of  the  operation,  one  in  which  it  was  in- 
accessibly placed  in  the  ureter. 

The  removal  of  the  kiJney,  together  with  the  stone,  presents  itself  as 
a  much  more  dangerous  operation  than  simple  extraction  of  the  stone, 
13 


194         ox  THE  TREATMENT  OF  STONE  IN  THE  KIDNEY. 

and  probably  will  not  be  resorted  to  out  upon  failure  of  the  smaller  pro- 
ject. 

The  causes  of  death  after  renal  lithotomy  are  not  stated  in  every  fatal 
case,  but  it  is  to  be  remarked  that  extravasation  of  urine  finds  no  place 
among  them.  Of  four  cases  where  the  manner  of  death  is  stated  it  oc- 
curred from  sinking  in  tliree  instances;  from  pytemia  in  one.  Among 
the  results  of  nephrectomy  for  existing  stone  we  find  similar  dangers; 
shock  or  sinking  in  three  cases  ;  pyaemia  in  one.  Peritonitis  presented 
itself  as  a  cause  of  death  in  one  instance,  in  which  a  tuberculous  kidney 
Avas  exi)lored  for  stone,  but  did  not  occur  as  the  result  of  any  operation 
in  which  calculus  was  correctly  diagnosed.  Suppression  of  urine  occurred 
in  one  case  of  fatal  nephrectomy  in  which  no  stone  was  found. 

Grave  as  the  recorded  results  are,  thej^  are  encouraging  and  are  daily 
becoming  more  so;  we  owe  a  debt  of  gratitude  to  those  surgeons  whose 
enterprise  has  placed  renal  calculus  in  the  list  of  curable  diseases.  Mistakes 
of  diagnosis  can  scarcely  be  so  frequent  in  the  future  as  in  the  past,  and 
the  attempt  to  remove  bodily  a  kidney  from  which  a  stone  could  not  be 
extracted,  or  in  wliich  it  could  not  be  found,  is  an  addition  to  the  mor-- 
tality  which  may  be  avoided.  It  appears  that  a  kidney  may  be  laid  open 
from  or  exposed  behind  without  special  danger,  and  with  a  death  rate 
represented,  so  long  as  no  evisceration  be  attempted,  by  six  deaths  in 
twenty-two  cases.  It  is  to  be  expected  that  with  further  experience  the 
operative  process  will  improve,  and  to  be  hoped  that  in  future  surgical 
enterprise  may  be  more  successfully  guided  by  medical  judgment. 

The  system  is  tolerant  of  renal  calculi  more  so  than  of  vesical ;  with 
pain  slight,  and  danger  remote  or  hypothetical,  no  such  operation  as  in 
question  can  be  justifiable.  But  in  some  cases  the  pain  is  so  great  as  to 
warrant  much  risk  in  search  of  cure,  and  in  others  the  tendency  of  the 
disease  is  such  that,  should  an  operation  kill,  it  will  only  anticipate  by  a 
little  the  action  of  nature.  In  such  circumstances  it  maybe  right  to  cut 
for  stone  in  the  kidney,  accepting  the  teaching  of  experience  mainly  in 
two  respects — not  to  do  so  when  the  diagnosis  is  doubtful,  and,  in  doing 
it,  to  do  as  little  as  possible.  Another  rule  wliich  may  be  laid  down,  is 
not  to  cut  for  stone  if  the  renal  discharge  intermits  and  accumulates, 
since  this  habit  would  indicate  obstruction  in  the  ureter,  a  condition 
which  no  operation  would  be  likely  to  remove.  A  discouraging  considera- 
tion is  the  possibility  that,  if  the  stone  be  of  long  standing  and  ])re- 
sumably  phosphatic,  it  may  be  of  such  a  size  or  branched  in  such  a 
manner  as  to  make  its  removal  during  life  clearly  impracticable. 

The  frequency  with  which  stone  affects  both  kidneys  (about  one  case 
in  five)  can  scarcely  be  held  to  militate  against  the  operation.  The 
danger  of  it  may  be  somewhat  more  if  there  be  any  obstruction  of  the 
unconcerned  kidney;  but  in  this  case  there  is  the  greater  need  that  the 
risk  should  be  incurred,  since  it  is  an  attempt  to  remove  a  condition 
which  is  one  of  mortal,  though,  perhaps,  not  immediate  peril. 

Solvent  Treatment  of  Kenal  Stones. 

"When  an  imperfect  and  much  dreaded  process  of  lithotomy  was  the 
only  method  of  removing  stones  in  substance  from  the  bladder,  lithon- 
thryptics,  as  they  were  called,  were  sought  eagerly  and  not  without  suc- 
cess, though  the  composition  of  urinary  calculi  was  then  unknown,  and 
the  search  was  guided  solely  by  empirical  considerations.  Alkalies  were 
early  used  for  this  j^urpose.     Basil  Valentine  used  a  fixed  alkaline  salt  in 


ON  THE  TREATMENT  OF  STONE  IN  THE  KIDNEY.         195 

calculous  disorders,  and  Sennertus  in  similar  circumstances  is  said  to 
have  em|)lo3'ed  cream  of  tartar.  The  searcli  received  a  later  direction  from 
Joanna  Stephens.  Her  nostrums  for  the  solution  of  stone  having  be- 
come notorious,  Parliament,  acting  by  the  advice  of  a  scientific  com- 
mittee Avlio  put  her  ren;iedy  to  the  test  of  clinical  experiment,  bought  her 
secret  in  the  year  1739  for  £5,000,  and  made  it  public  as  follows  for  the 
benefit  of  mankind.'  "  My  medicines  are  a  powder,  a  decoction,  and 
j)ills.  The  powder  consists  of  eggshells  and  snails,  both  calcined.  The 
decoction  is  made  by  boiling  some  herbs  (together  with  a  ball  wliich  con- 
sists of  soap,  swine's  cresses  burnt  to  blacivuess,  and  honey)  in  water. 
Tiie  pills  consist  of  snails  calcined,  wild  carrot  seeds,  burdock  seeds, 
ashen  keyes,  hips  and  hawes,  all  burnt  to  blackness,  soap  and  honey." 
Tlie  powder  was  given  in  drachm  doses;  the  decoction  by  half-pints. 
The  pills,  which  were  luirchased  by  quarts,  were  swallowed  at  the  rate 
of  fifty  or  sixty  a  day,  in  weight  about  two  ounces.* 

Calcined  eggshells  and  soap  had  been  long  esteemed  as  lithonthryp- 
tics,  as  also  had  most  of  the  vegetable  ingredients  of  her  charred  and 
nauseous  mass.  The  essentials  of  the  mixture  were  lime  and  soap,  or, 
in  other  words,  lime  and  potash,  since  in  considering  the  remote  action 
of  the  soap  we  may  put  aside  the  oil  and  have  regard  only  to  the  alkaline 
bases,  which  Avith  Alicant  or  Castile  soap  are  lime  and  potash.  Thus  a 
powerful  alkaline  remedy  was  given  in  large  doses  with  the  effect,  as  we 
learn  from  the  case  published  by  Dr.  Parsons,  of  making  the  urine 
alkaline  and  keeping  it  so  for  months.  Mrs.  Stevens'  alkalies  did  not 
cure,  but  it  is  evident  from  the  published  cases  that  they  often  much 
alleviated,  and  even  when  they  apparently  did  the  reverse  they  did  not 
fail  to  encourage  the  patient  by  engendering  phosphatic  sand  and  grit, 
which  he  fondly  attributed  to  disintegration  of  the  stone.  After  the 
death  of  a  man  (Mr.  Gardner)  whose  supposed  cure  had  helped  to  make 
the  fame  of  the  medicine  and  the  fortune  of  the  proprietor,  no  less  than 
nine  stones  were  found  in  his  bladder.  These  had  become  sacculated  in 
such  a  manner  as  to  elude  the  experienced  sound  of  Cheselden.' 

In  spite,  however,  of  this  solution,  rather  of  the  doubt  than  the  stone, 
soap,  lime,  and  alkalies  continued  to  be  introduced  in  all  shapes,  both  by 
the  mouth  and  by  the  urethra,  in  calculous  affections  of  every  kind. 
There  is  still  to  be  seen  in  tlie  College  of  Surgeons  a  large  saponaceous 
mass,  which  had  accumulated  in  the  bladder  as  the  result  of  this  misdi- 
rection of  a  valuable  external  ai)plication.  Subsequently,  when,  owing 
in  great  measure  to  the  researches  of  Wollaston,  the  nature  of  urinary 
calculi  began  to  be  understood,  alkalies  by  themselves  came  to  be  exten- 
sively used.  Dr.  Marcet,  in  the  year  1819,  pointed  out  that  the  alkalies, 
which  he  recommended  as  bicarbonates,  could  exert  a  solvent  action  only 
u])on  lithic  acid,  while  phosphatic  concretions  might  be  aggravated  or 
originated  by  their  use.  He,  however,  despaired  of  materially  lessening 
large  concretions  of  any  kind  in  this  manner,  having  regard  to  the  small 
surface  tliey  exposed  in  relation  to  their  bulk,  and  limited  the  use  of  alka- 
lies to  the  correction  of  the  uric  acid  diathesis,  the  prevention  of  the  in- 
crease of  existing  calculi  and  the  formation  of  fresh  ones,  and  to  such  sol- 
vent action  upon  small  stones  and  gravel  as  might  round  their  edges, 

'  Extracted  by  Sir  Henry  Thompson  from  the  Oeiitlenian's  Magazine,  June, 
1739,  vol.  ix.  p.  298. 

''  See  Parsons  Lithonthryptics.    London,  1754.     Case  of  Mr.  Gai-dener. 
^  Parsons,  loc.  cit. ,  p.  2;J6. 


196  ON    THE    TREATMENT    OF    STONE    IN    THE    KIDNEY. 

and  enable  them  to  make  easy  exit.  For  practical  purposes  the  problem 
still  stands  much  as  he  left  it.' 

The  solution  of  urinary  calculi  was  subsequently  investigated,  at  the 
instance  of  the  Academy  of  Sciences,  by  Gay  Lussac  and  Pelouze,  with 
reference  to  the  researches  of  d'Etoilles  upon  the  subject.  The  results  ^ 
were  published  in  the  year  18-42.  Experiments  were  made  upon  different 
sorts  of  calculi  and  with  various  reputed  solvents,  of  which  the  alkaline 
carbonates  received  most  consideration.  Stones  were  exposed,  even  for 
a  year,  to  solutions  containing  from  1  to  2  per  cent  of  the  carbonates  of 
potash  or  soda.  None  were  dissolved;  some  were  not  even  diminished 
in  bulk.     They  had  lost  from  a  quarter  to  half  their  original  weight. 

In  another  experiment  fragments  were  ex^iosed  for  three  months  to 
a  stream  of  water  holding  in  solution  one-twentieth  of  its  weight  of  car- 
bonate of  soda.  The  fragments  did  not  generally  lose  volume,  but  be- 
came friable,  and  lost  from  ten  to  sixty  per  cent  of  weight. 

After  such  experiments,  and  others  upon  the  living  body,  in  which 
alkaline  carbonates  were  given  as  medicine,  and  passed  as  injections  into 
the  bladder,  the  Commission  reported  that,  without  denying  the  possi- 
bility of  the  cure  of  stone  by  solution  in  certain  cases,  they  were  of  opin- 
ion that  unless  the  calculi  were  small  they  were  not  likely  to  be  destroyed 
by  agents  acting  indirectly,  as  baths  or  potions,  and  that  as  to  solvents 
applied  directly  by  injection,  though  they  acted  more  powerfully,  yet 
the  process  was  attended  with  difficulty  and  danger,  not  counterbalanced, 
as  in  lithotrity,  by  the  prospect  of  speedy  cure.  Finally,  the  Commission 
suggested  that  the  plan  might  be  of  use  in  conjunction  with  lithotrity, 
where  a  large  surface  was  exposed  by  fracture  to  the  action  of  the 
solvent. 

Front,'  writing  in  1843,  spoke  hopefully  of  the  solution  of  stone  by 
medicine,  but  did  not  materially  add  to  the  previous  knowledge  of  the 
subject.  He.  believed  healthy  urine  to  have  in  itself  a  certain  amount  of 
solvent  power  over  concretions  of  lithic  acid.  Medicinally,  in  the  treat- 
ment of  such  stones  he  recommended  Vichy  Avater,  or  the  alkaline  bicar- 
bonates,  giving  the  preference  to  potash,  which  he  advised  in  quantities 
of  from  one  to  two  drachms  a  day,  with  an  equal  quantity  of  tartarated 
soda.  He  used  these  salts  in  solutions  containing  an  excess  of  carbonic 
acid,  in  which  shape  he  attributed  them  to  a  peculiar  disintegrating 
power.  He  thought  that  by  such  means  ''an  impression  might  be  made " 
on  calculi  in  the  kidney  or  bladder,  but  admits  that  the  method  is  long, 
tedious,  and  uncertain.  He  restricts  the  use  of  solvents  by  injection  to 
the  employment  of  acids  in  the  jihosphatic  diathesis. 

More  recently  the  subject  has  been  resuscitated  by  the  researches  of 
Dr.  William  Roberts,^  which  enable  us  to  direct  the  old  remedies  with 
new  precision;  though  it  must  still  be  admitted  that  the  dissipation  of 
stones  of  bulk  by  agents  which  have  to  traverse  the  general  circulation  is 
a  matter  of  hope  rather  than  experience. 

After  this  indication  of  the  steps  by  which  it  has  been  reached,  our 
present  knowledge  of  the  subject  may  be  easily  disjilayed,  so  far  as  it 
bears  upon  the  subject  of  this  treatise. 

Phosphatic  stones  are  soluble  in  dilute  acids.     Uric  acid,  the  urates, 

'  Marcet  on  Calculoxis  Disorders,  1819,  p.  152. 
^  Coinptes  Rendus,  vol.  xiv.  p.  429. 
^  On  Stomach  and  Renal  Diseases,  3d  edit.  p.  424  et  seq. 

*  Transactions  Med.  Chir.  Society,  1865.  "  On  Urinary  and  Renal  Dis- 
eases," edit.  2,  p.  290. 


ox  THE  TREATMENT  OF  STONE  IX  THE  KIDNEY.        197 

"and  cystine  are  soluble  in  dilute  alkalies.  Oxalate  of  lime  is  not  soluble 
in  anything  Avhicli  the  tissues  can  tolerate,  and  may  be  at  once  excluded 
from  consideration. 

With  regard  to  acid  solvents,  as  there  is  no  way  of  causing  the 
urine  to  be  secreted  so  acid  as  to  act  upon  stones,  they  can  only  be  ap- 
plied by  the  urethra  and  to  the  vesical  cavity.  Stones  in  the  kidney  are 
out  of  their  reach.  The  coats  of  the  bladder  will  endure  a  solution  of 
nitric  acid  strong  enough  to  produce  the  slow  dissolution  of  phosphatic 
calculi,  and  I  have  seen  this  means  resorted  to,  though  vainly,  in  the 
treatment  of  a  concretion  of  this  character  which  was  considered,  justly, 
as  it  turned  out,  too  large  to  be  dealt  with  by  either  cutting  or  crushing. 
The  case  must  be  quite  exceptional  in  which  this  tedious  and  uncertain 
method  can  be  preferred  to  the  recognized  surgical  expedients.  It  w^ould 
jseem  to  have  its  use,  as  long  ago  suggested,  rather  as  an  adjunct  to  lithot- 
rity  than  as  a  substitute  for  it.  In  a  case  mentioned  by  Dr.  Roberts,' 
the  fragments  left  after  the  operation  Avere  dissolved,  and  the  formation 
of  fresh  phosphatic  matter,  to  Avhich  there  was  a  great  tendency,  was 
prevented  by  the  injection  every  day,  or  every  other  day,  of  a  solution  of 
two  drachms  of  dilute  nitric  acid  to  a  pint  of  water.  The  treatment  of 
Tesical  stones,  however,  to  which  only  this  method  applies,  is  foreign  to 
the  design  of  this  work. 

With  regard  to  stones  which  remain  in  the  kidney,  the  question  re- 
duces itself,  in  the  present  state  of  our  knowledge,  to  the  solvent  action 
of  urine,  alkalized  by  the  mouth.  Solvents  can  reach  renal  calculi  only 
by  secretion,  and  those  only  which  are  alkaline  can  be  thus  conveyed. 
The  stones  which  we  can  ho])e  to  affect  in  this  way  are  uric  acid,  the 
urates,  and  cystine;  uric  acid  as  the  most  common,  must  be  chiefly  con- 
sidered. 

The  belief  in  the  efficacy  of  lime-water  as  a  solvent  for  calculi,  which 
prevailed  in  the  last  century,  with  the  evidence  which  was  adduced,  at 
least  of  relief  by  it,  together  with  the  present  commendations  to  the 
same  end,  of  calcareous  waters,  make  it  of  interest  to  look  somewhat 
narrowly  at  the  powers  of  solution  which  this  earth  possesses,  and  can 
impart  to  the  urine.* 

Lime-water  out  of  the  body  will  dissolve  uric  acid  and  disintegrate 
calculi  mainly  consisting  of  it,  and  lead  to  their  destruction  more  readily, 
at  least,  than  any  of  the  alkaline  carbonates.  A  piece  of  uric  acid  calcu- 
lus soaked  in  lime-water,  which  was  frequently  renewed,  became  so  fri- 
able in  three  weeks  as  to  break  at  a  touch,  while  in  six  weeks  it  had 
crumbled  so  neai'ly  to  powder  that  no  fragments  remained  but  such  as 
would  have  readily  escaped  by  tlie  urethra.  Similar  portions  of  the 
fiame  stone  scarcely  lost  percei)tibly  in  solutions  of  carbonate  of  i)otash 
and  of  ammonia;  while  in  carbonate  of  soda  and  in  carbonate  of  ammo- 
nia they  underwent  a  slight  increase  of  weight.  Next  to  lime-water, 
the  greatest  disintegration  in  this  experiment  was  effected  by  pure 
water. 

Thus,  if  lime-water  could  traverse  the  system  as  such,  and  reach  the 
bladder  with  its  jiroperties  intact,  it  would  clearly  be  an  efficaceous  and 
safe  lithonthr3'ptic  as  far  as  uric  acid  is  concerned.  But  it  is  sufficiently 
clear  that  lime  given  by  tiie  mouth  cannot  reappear  in  the  urine  either 
as  the  calcic  oxide,  or  even  as  the  carbonate. 

'  On  Urinary  and  Renal  Disease,  2d  edit.,  p.  313. 

^  Essay  on  the  Virtue  of  Linie-Water  and  Soap  in  the  Cure  of  the  Stone.  By 
Robert  Whytt,  M.D.     Edinburgh,  17(31.     Alston's  Materia  Medica,  1770. 


198  ON    THE    TREATMENT    OF    STONE    IN    THE    KIDNEY. 

The  calcic  oxide  must  necessarily  form  salts  in  the  blood,  and  thus 
lose  the  activity  which  belonged  to  it  before;  while  the  earth  can- 
not emerge  in  the  urine  as  a  carbonate  by  reason  of  the  insolubility 
of  that  compound.  It  can  reach  the  urine  only  as  a  salt,  presum- 
ably a  phosphate  to  which  we  have  no  reason  to  attribute  any 
such  solvent  power  as  the  alkaline  earth  possesses.  But  although 
lime  cannot  enter  the  urine  in  a  free  state,  or  as  carbonate,  it  yet  has  the 
power  of  making  the  urine  alkaline,  and  upon  this  depends  any  action 
it  may  liave  upon  uric  acid.  The  urine  may  be  made  alkaline  by  lime- 
water,  by  the  Liquor  Calcis  Saccharatus,  or,  more  conveniently,  by  the 
acetate  of  lime,  which  is  decomposed  in  the  body,  and  has  much  the  same 
ultimate  effect  as  a  corresponding  quantity  of  lime-water.  The  amount 
of  this  water  needed  to  make  the  urine  alkaline  is,  of  course,  very  large, 
as  were  the  doses  given  of  old — two  quarts  a  day,  for  example.  With  the 
addition  of  the  saccharate  the  same  effect  can  be  accomplished  without 
preposterous  dosage.  Of  the  acetate  I  have  found  from  'Z  to  12  drachms 
daily,  according  to  age  and  circumstance,  effective  in  making  ordinarily 
acid  urine  alkaline. 

Lime  thus  given  probably  leaves  the  system  largely  by  the  bowels,  but 
somewhat  with  the  urine.  It  may  sometimes  be  noted,  however,  that 
the  urine  becomes  alkaline  before  it  disphiys  any  increased  precipitate 
with  liquor  potass*,  or,  in  other  words,  before  any  of  the  lime  so  admin- 
istered has  reached  it.  The  alkalescence  is  due  to  the  potash  and  soda 
which  the  lime  has  displaced.  If  the  urine,  therefore,  in  such  a  case 
has  any  solvent  power,  it  owes  it  to  these  alkalies,  not  to  the  lime.  In- 
deed, it  is  clear,  from  the  reasons  I  have  stated,  that  the  lithonthryptic 
properties  of  this  caustic  earth  cannot  survive  transit  by  the  blood,  in 
which  phosphoric  acid  abounds  ;  but  nevertheless  it  makes  the  urine 
alkaline,  and  thus  a  solvent  of  uric  acid,  whatever  the  immediate  cause 
of  the  alkalescence  be.  But  if  lime  is  to  make  the  urine  alkaline  by  the 
agency  of  potash  and  soda,  it  only  does  indirectly  and  with  concomitant 
risk  what  can  be  done  directly  and  safely.  Lime  promotes  the  forma- 
tion of  the  oxalates  in  acid  urine,  of  the  phosphates  in  alkaline.  The 
alkalies  may,  indeed,  increase  the  deposition  of  the  phospluites,  but  not 
of  the  oxalate.  Lime,  therefore,  as  a  solvent  of  uric  acid  by  the  mouth 
is  inferior  to  the  alkalies.  If  the  question  were  the  solution  of  uric  acid 
by  injection  into  the  bladder,  lime  would  be  more  effective  than  any- 
thing but  liquor  potassge,  than  which  it  might  prove  to  be  better  borne. 
But  with  lithotrity  possible,  injection  need  not  be  consitlered. 

It  is  scarcely  needful  to  add  a  corollary  touching  the  use  of  calcareous 
waters,  such  as  those  of  Contrexeville,  which  have  been  vaunted  as  sol- 
vents or  expellers  of  gravel.  Contrexeville  is  a  slightly  alkaline  calcareous 
water.  It  contains  sulphate  of  lime  in  chief  (in  a  proportion  of  about 
1.2  in  a  thousand  parts)  with  smaller  quantities  of  the  carbonates  of 
lime,  magnesia,  and  soda,  and  other  salts.  This  is  drunk  at  the  rate  of 
twenty  or  thirty  glasses  a  day,  with  the  obvious  results  of  diuresis  and 
sometimes  purgation,  and  the  reputed  effects  of  bringing  away  gravel 
and  relieving  gout  and  vesical  catarrh.  It  may  well  be  believed  that 
scanty  urine  may  be  made  abundant,  over  acid  urine  not  so,  that  gravel 
may  be  washed  from  tiie  pelvis  and  tubes,  and  that  the  salutary  conse- 
quences of  irrigation  may  be  wrought  in  a  system  loaded  with  the  ]n-o- 
ducts  of  inactivity  and  excess  ;  but  whether  all  this  would  not  be  better 
done  by  some  non-calcareous  water  is  a  question  to  be  asked.  I  do  not 
know  whether  stone  is  especially  common  among  the  natives  of  Contrexe- 


ON   THE    TREATMENT    OE    STONE    IN    THE    KIDNEY.  199 

ville,  bat  we  know  enough  of  the  endemic  influence  of  calcareous  water  in 
our  own  country,  to  make  us  cautious  in  the  use  of  it  wliere  a  calculous 
proclivity  exists.  And  it  has  been  already  sliown  that  lime-salts  taken  by 
the  mouth  impart  no  solvent  ])ower  to  the  urine  which  may  not  be 
equally  given  by  other  means.  Lithia  is  more  promising  than  lime  in 
respect  of  the  solubility  of  its  carbonate,  which  appears  to  reach  the 
urine  and  act  there  according  to  its  kind.  I  shall  postpone  what  I  have 
to  say  of  this  earth  until  after  the  consideration  of  potash,  with  which  it 
may  with  convenience  be  compared.  Soda  must  be  at  once  discarded. 
Urate  of  soda  is  a  difficultly  soluble  substance  of  greater  bulk  than  the 
uric  acid  of  which  it  was  formed,  so  that  salts  of  soda  may,  under  certain 
circumstances,  lead  to  the  increase  of  uric  acid  calculi  rather  than  their 
decrease.  I  found  that  a  fragment  of  a  stone  of  this  nature  had  added  one- 
seventh  to  its  weight  in  a  week,  by  a  rough  incrustation  which  a  solution 
of  carbonate  of  soda  had  imparted  to  it.  Hence,  soda  must  be  put  aside, 
and  with  it  the  numerous  waters,  with  Vichy  at  their  head,  which  owe 
their  alkalinity  to  it. 

A  word  may  be  said  in  passing  as  to  the  action  of  ammonia.  Though 
this  alkali  is  not  secreted  by  the  kidneys  when  given  by  the  mouth,  yet 
its  carbonate  is  so  often  present  in  the  urine  as  a  product  of  decomposi- 
tion, that  its  action  upon  stones  is  not  without  interest.  Ammonia  and 
its  carbonate  have  in  water  an  effect  upon  uric  acid  which  is  comparable 
to  that  exerted  by  the  fixed  alkalies  and  their  carbonates — forming  an 
urate  which  may  be  either  dissolved  or  left  as  an  incrustation — but  in 
urine  ammonia,  whether  free  or  as  carbonate — the  carbonate  only  need  be 
considered — produces  such  a  deposition  of  the  triple  or  mixed  phosphates 
that  any  stone  which  may  be  present  is  both  increased  thereby  and  pro- 
tected from  any  solution  that  might  otherwise  be  possible.  Neverthe- 
less, it  may  be  supposed  that  if  an  uric  acid  stone  or  part  of  it  be  kept 
clear  by  friction,  a  certain  amount  of  solution  may  in  course  of  time  be 
produced  by  the  ammoniacal  products  to  which  itself  has  given  rise,  and 
thus  may  probably  be  explained  the  signs  of  spontaneous  solution  which 
are  sometimes  to  be  discerned  upon  the  calculi. 

Dr.  Eoberts  came  to  the  conclusion  that  salts  of  potash  were  more 
effective  as  solvents  of  uric  acid  calculi  than  those  of  soda  or  lithia,  and 
that  of  carbonate  of  potash  in  particular,  the  solvent  power  was  up  to 
a  certain  point  increased  by  dilution,  the  maximum  action  upon  the 
uric  acid  belonging  to  a  solution  of  sixty  grains  to  the  imperial  pint. 
With  increasing  strength  the  solution  was  arrested  by  an  incrustation  of 
biurate  of  pota.sh,'  insoluble  in  all  but  very  dilute  solutions,  which  pro- 
tected the  stone  from  further  action.  AVith  solutions  containing  from 
forty  to  sixty  grains  to  the  pint,  tiiere  was  scarcely  any  accumulation  of 
this  material,  as  it  was  removed  as  fast  as  formed;  with  eighty  grains 
there  was  a  loose,  with  120  grains,  a  tenacious  coat. 

Having  ascertained  the  material  and  the  strength  of  solutions  which 
have'the  greatest  })ower  of  dissolving  uric  acid  out  of  the  body,  the  next 
step  is  to  impart  to  the  urine  within  it  the  needful  amount  of  tiie  need- 
ful substance.  The  salts  which  the  alkalies  form  with  the  vegetable  acids 
appear  in  the  urine  as  carbonates,  a  fact  which  as  regards  citrate  of 
potash  Avas  originally  pointed  out  by  Sir  Gilbert  Blane.  AVith  potash, 
for  example,  the  urine  will   equally  contain  its  carbonate  whether  the 

'  See  Dr.  Robei-ts  on  the  solvent  power  of  strong  and  weak  solutions  of  the  alka- 
line carbonates  on  uric  acid  and  calculi.  Report  of  British  Association  for  1%Q\, 
p.  90. 


200         ON  THE  TREATMENT  OF  STONE  IN  THE  KIDNEY. 

alkali  be  given  in  a  caustic  state,  as  bicarbonate,  or  as  tartrate,  acetate, 
or  citrate.  Of  these  preparations  the  citrate  a])pears  to  create  tlie  least 
disturbance.  It  may  indeed  be  given  in  quantity  sufficient  to  keep  the 
urine  alkaline  for  an  almost  unlimited  time  without  injuriously  affecting 
the  stomach  or  bowels,  without  causing  vesical  irritation,  Avithout  causing 
the  patient  to  lose  weiglit  or  strength,  or  hurting  the  health  in  any  man- 
ner. A  man  whom  I  treated  unsuccessfully  for  a  presumed  uric  acid  stone 
in  his  kidney  took  a  drachm  of  citrate  of  potash  every  four  hours  for 
nearly  five  months,  during  which  time  his  urine  was  constantly  alkaline. 
Under  the  treatment  he  gained  slightly  in  weight,  lost  an  appearance  of 
anaemia  which  he  had  at  its  commencement,  and  improved  in  general 
health.  Sligiit  nocturnal  frequency  of  micturition  was  the  only  undesir- 
able consequence  which  was  noticed.  From  this  and  many  similar  ex- 
periences, including  those  afforded  by  the  alkaline  treatment  of  acute 
rheumatism,  it  is  certain  that  most  persons  can  take  the  citrate  of 
potash  and  other  neutral  salts  of  the  alkalies  in  considerable  doses,  and 
for  a  considerable  time,  without  liarm. 

I  must  here  say  a  Avord  about  lithia,  which  as  a  lithonthryptic  is  more 
encouraging  to  the  chemist  than  the  physician.  Dr.  Garrod,  as  is  Avell 
known,  has  been  led  to  the  belief  that  this  earth  is  a  more  active  solvent 
for  uric  acid  than  potash,  Avhile  Dr.  Eoberts  has  come  to  the  contrary 
conclusion.  I  have  made  many  experiments,  in  which  fragments  of 
uric  acid  stones  have  been  exposed  under  the  same  circumstances  to  the 
action  of  carbonate  of  lithia  and  carbonate  of  potash,  and  I  have  found 
as  a  constant  result  that  outside  the  body  the  earth  has  dissolved  more 
than  tlie  alkali.  Among  others  I  may  briefly  relate  three.  Of  the  first 
the  subject  was  a  small  stone,  nine-tenths  of  which  consisted  of  uric  acid 
and  urates,  one-tenth  of  phosphates.  Three  similar  portions,  each 
weighing  .377gramme,  were  suspended  each  in  six  pints  of  liquid,  one  in 
distilled  water,  one  in  a  solution  of  carbonate  of  potash,  a  drachm  to 
each  pint  of  distilled  water,  one  in  a  solution  of  carbonate  of  lithia  of 
the  same  strength.  After  nineteen  days  of  the  month  of  June  the  stone 
in  water  was  found  to  weigh  .365  gramme,  that  in  potash  .254,  much 
encrusted,  that  in  lithia  .091,  clean  and  so  friable  as  to  crumble  at  a 
touch.  The  Avater  had  taken  aAvay  a  thirty-first,  the  potash  a  third,  the 
lithia  three-fourths.  Another  experiment  dealt  with  two  similar  por- 
tions of  a  large  stone  of  almost  pure  uric  acid,  each  of  Avhich  Aveighed 
2.775  grammes.  One  of  these  Avas  suspended  in  a  solution  of  carbonate 
of  potash  in  distilled  Avater,  half  a  drachm  to  10  ounces,  the  other  in  a 
similar  solution  of  carbonate  of  lithia.  Both  were  kept  in  a  Avater  oven 
at  a  mean  temperature  of  100°  Fahr. ;  the  solutions  Avere  changed  every 
day  but  the  stones  not  touched.  After  four  days  and  nights,  the  piece  in 
lithia  had  become  so  attenuated  that  the  experiment  Avas  discontinued 
lest  there  should  be  nothing  to  shoAv;  what  remained  Aveighed  .404 
gramme,  six-se\'enths  having  gone;  what  Avas  left  was  uncoated  and  ex- 
tremely friable.  The  piece  in  potash  Avas  covered  Avith  a  brittle  Avhite 
crust  including  Avhicii  it  Aveighed  2.053,  having  lost  a  little  over  a  quarter 
of  its  Aveight.  In  the  last  experiment  to  which  I  need  refer,  tAvo  portions 
of  the  same  stone  as  in  the  preceding  were  treated  similarly  in  all  respects 
except  that  they  were  brushed  tAvice  a  day  so  as  to  remoA'e  any  crust 
which  might  form,  as  might  be  presumed  to  be  done  Avithin  the  body  by 
movement.  Each  piece  Aveighed  at  starting  .728  gramme.  After  tliree 
days  and  nights  the  stone  in  lithia  had  been  reduced  to  .042,  and  in 
potash  to  .225.     The  inferior  result  from  the  potash  thus  appears  to  be 


ON  THE  TREATMENT  OF  STONE  IN  THE  KIDNEY.         201 

due  not  only  to  the  protecting  effect  of  the  crust  which  forms  more  abun- 
dantly with  this  agent,  but  to  the  superior  solvent  power  of  the  lithia 
upon  uric  acid. 

Accepting  this  conclusion  as  constant  out  of  the  body,  we  come  to  the 
most  unsatisfactory  part  of  the  question.  The  salts  of  litliia,  whether 
carbonate  or  citrate,  are  not  tolerated  in  anything  like  the  quantities  in 
which  potash  can  be  generally  given  with  impunity,  and  cannot  be  suita- 
bly employed  so  as  to  keep  the  urine  constantly  alkaline.  Whatever 
value  lithia  may  have  in  doses  short  of  this  result,  it  appears  that 
enough  to  accomplish  it  generally  produces  disagreeable  consequences — 
headache,  sickness,  trembling,  and  dimness  of  sight.  I  have  given  for 
short  periods  as  much  as  half  a  drachm  of  the  citrate  or  carbonate  every 
four  hours,  with  the  effect  of  rendering  the  urine  quickly  and  decidedly 
alkaline;  could  we  continue  the  drug  in  anything  like  these  quantities 
we  might  find  the  solution  of  caculi  within  the  body  practicable,  but 
it  is  sufficiently  clear  that  such  doses  cannot  be  long  borne,  and  indeed 
it  would  appear  that  in  ordinary  circumstances  the  alkalinity  necessary 
to  the  solution  of  calculi  cannot  be  long  maintained  by  lithia  with- 
out such  constitutional  disturbance  as  would  call  for  its  discontinu- 
ance. 

It  must  be  borne  in  mind  that  there  are  those  to  whom  alkalies  of  any 
kind  are  i'»eculiarly  inimical.  The  class  is  small  but  easy  of  recognition. 
The  disturbances  which  belong  to  it,  as  elsewhere  detailed,  though  often 
having  a  superficial  resemblance  to  those  in  which  alkalies  are  of  use, 
present  essential  differences  to  them.  The  individuals  referred  to  are  of 
nervous  temperament,  and  have  one  form  of  what  has  been  called  the 
phosphatic  diathesis.  The  urine,  which  may  be  naturally  or  over  acid, 
but  perhaps  more  often  is  wanting  in  acidity,  is  pale,  copious,  and  gives  a 
bulky  precipitate  with  liquor  potassae  in  consequence  of  the  excess  of  earthy, 
chiefly  of  lime,  salts  which  it  contains.  Oxalate  of  lime  and  the  crystal- 
line phosphate  are  of  frequent  occurrence  as  spontaneous  deposits,  and  if 
calculi  are  found  they  are  apt  to  be  of  the  oxalate  or  some  other  earthy 
salt.  Uric  acid  is  seldom  thrown  down.  Lithates,  if  they  occur,  are 
pale,  not  red.  These  characters  of  the  urine  are  conjoined  with  a  sensi- 
tive, mobile,  and  often  intellectual  character.  There  is  bodily  as  well  as 
mental  activity,  and  an  aspect  tending  to  i)allor,  or  at  least  not  rubicund. 
Such  persons  are  tremulous,  neuralgic,  and  liable  to  slight  and  partial 
ana3sthesia,  especially  as  numbness  in  the  legs.  The  tongue  is  apt  to  be 
tremulous,  and  as  if  boiled,  anasmic,  uniformly  coated,  and  wliat  is 
called  oedematous.  All  these  conditions  are  aggravated  by  mental  dis- 
turbance, under  which  the  amount  of  lime  in  the  urine  is  at  once  in- 
creased, possibly  as  an  evident  crystalline  deposit.  With  these  persons 
gout  take  an  asthenic  shape;  if  they  have  rheumatic  fever  it  is  not  with 
the  acute  symptoms  and  acid  overi)lus  common  to  others,  or  with  the 
same  liability  to  cardiac  complications.  Thus  their  diseases  do  not  sug- 
gest alkalies,  and  should  such  drugs  be  inadvertently  administered  their 
inappropriateness  is  shown  by  early  alkalinity  of  urine,  the  aggravation 
of  any  neuralgic  symptoms  that  may  exist,  the  tongue  at  the  same  time 
turning  more  white,  sodden,  and  shaky,  and  by  increasing  malaise  and 
nervous  prostration.  Persons  in  general,  however,  and  especially  those 
who  deposit  uric  acid,  endure  alkalies  well  enough  to  allow  of  their  free 
and  protracted  use.  By  such  means  considerable  vesical  stones  have  been 
so  acted  upon  as  to  show,  after  their  removal  from  the  bladder,  evident 
signs  of  solution;  small  ones  have,  it  is  believed,  been  entirely  dissolved 


202         ON  THE  TKEA.TMENT  CF  STONE  IN  THE  KIDNEY. 

or  reduced  to  viable  size.  With  stones  in  the  kidney,  this  amount  of 
success,  small  as  it  is,  appears  to  have  been  seldom  attained,'  though  Dr. 
Ralfe  has  recently  related  an  instance  in  which  one  came  away  in  an  at- 
tenuated state,  owing  as  was  thought  to  alkalies  and  soft  water.  Stones 
in  the  pelvis  are  probably  less  effectively  exposed  to  the  action  of  the 
urine  tiian  in  the  bladder.  Renal  calculi  are  washed,  vesical  are  soaked. 
The  bladder  usually  contains  urine  in  which  the  stones  lie  more  or  less 
completely  and  constantly  exposed  to  its  influence.  The  pelvis  is  gener- 
ally empty,  or  nearly  so,  the  urine  leaving  it,  except  under  constrained 
positions  of  the  body  or  morbid  obstruction,  almost  as  fast  as  it  enters,  so 
that  calculi  here  lodged  are  only  acted  upon,  and  that  transiently,  by  as 
much  of  the  secretion  as  trickles  over  their  surface. 

The  solvent  plan  must,  as  has  been  shown,  be  practically  limited  to 
concretions  composed  almost  entirely  of  uric  acid  or  urates,  or  the  two 
together.  With  this  in  view  it  becomes  of  importance  that  we  should 
know  the  numerical  chance  that  the  stone  is  of  material  thus  soluble. 
The  table  (page  122)  which  has  been  already  explained,  was  compiled 
with  this  object.  Thence  it  appears  that  of  ninety-one  renal  calculi  in 
the  museums  of  London,  twenty-one  were  wholly  composed  of  uric 
acid,  three  of  urates,  seven  of  uric  acid  and  urates  together, 
and  two  of  cystine.  These,  thirty-three  in  number,  comprise  all, 
even  theoretically,  assailable  by  alkaline  solvents.  For  practical  pur- 
poses we  may  exclude  the  rare  cystine  stones,  the  solution  of  which 
has  as  yet  received  little  attention,  and  regard  as  amenable  to  the 
alkaline  treatment,  only  those  calculi  which  consist  of  uric  acid 
and  the  urates.  These,  as  it  is  seen,  comprise  almost  exactly  a  third  of 
the  whole  number.  It  must  be  borne  in  mind,  however,  that  the  calculi 
enumerated  were  with  few  exceptions  taken  from  the  body  after  death. 
They  had,  therefore,  had  the  utmost  time  to  gather  phosphates  and  re- 
move themselves  from  the  class  of  soluble  stones.  It  is  probable  that, 
at  an  earlier  period,  a  few  of  them  may  have  consisted  wholly  of  uric 
acid  and  been  possible  subjects  for  solution.  But  it  is  evident  from  the 
fact  that  the  compound  calculi  have  more  often  a  nucleus  of  oxalate  of  lime 
than  of  uric  acid,  that  the  number  at  any  time  soluble  by  alkalies  never 
could  have  amounted  to  one-half.  It  may  be  observed  that  thirty-nine 
of  the  ninety-one  calculi  whicii  contained  either  a  phosphatic  deposit  or 
carbonate  of  lime,  had  necessarily  been  associated  at  some  period  of  their 
growtii  with  alkaline  urine,  and  were  therefore  not  only  insoluble  in 
alkalies  but  were  liable  to  derive  fresh  accretion  from  alkalization.  It 
will  be  readily  inferred  that  the  causes  of  renal  calculi  amenable  to  alka- 
line treatment  are  proportionately  few.  The  stone  must  be  of  pure  uric 
acid,  or  at  least  must  contain  no  admixture  but  urates.  It  must  also  be 
of  small  size.  If  the  urine  be  alkaline,  it  may  be  presumed  that  a  phos- 
l^hatic  crust  exists,  and  all  such  cases  must  be  discarded.  If  the  stone  be 
of  long  standing,  a  similar  condition  must  be  suspected,  notwithstanding 
that  the  urine  retains  its  acidity,  and  a  similar  encasement  must  also  be 
apprehended,  should  the  urine  contain  much  pus  or  mucus  of  renal 
origin.  If  oxahite  of  lime  habitually  exist  in  the  urine,  it  may  be  pre- 
sumed also  to  occur  in  the  stone,  and  must  also  contra-indicate  solvent 
remedies. 

In  the  absence  of  all  these  prohibitions,  perhaps  the  least  hopeless 
subjects  are  children.     Uric  acid  concretions  occur  especially  at  an  early 

1  Path.  Trans.,  vol.  xxxiii.  p.  20G. 


ON    THE    TREATMENT    OF    STONE    IN    TilE    KIDNEY.  203 

age,  and  when  crystals  are  habitually  passed  it  is  often  easy  to  arrive  with 
some  confidence  at  a  belief  that  there  exists  a  small  renal  stone  of  this 
nature.  With  children  the  stone,  necessarily  recent,  is  probably  small 
and  simple. 

Given  a  suitable  case,  citrate  of  potash  must  be  accepted  as  the  best 
material  for  charging  the  urine  with  the  desired  carbonate;  the  dose  to 
impart  the  greatest  solvent  effect  is  for  the  adult,  as  Dr.  Roberts  has 
shown,  from  40  to  60  grains  every  three  hours,  in  three  or  four  ounces  of 
water.     Two  conditions  may  arrest  the  solvent  process. 

If  the  urine  become  ammoniacal  the  treatment  must  be  discontinued, 
as  then  the  mixed  pliosphates  will  be  apt  to  be  deposited  as  an  insoluble 
crust.  It  is  beyond  question  that  by  this  state  of  urine  stones  have  often 
been  increased  and  multiplied.  Secondly,  it  is  needful  to  guard  against 
a  too  great  alkalinity  of  urine  from  fixed  alkali,  since,  as  has  been 
shown,  under  this  influence  the  stone  may  become  incrusted  with  the  in- 
soluble alkaline  biurate.  Thus  dangers  of  two  kinds  lie  in  the  direction 
of  over-alkalinity.     It  is  safer  to  give  too  little  alkali  than  too  much. 

It  is  a  matter  of  common  experience  that  the  symptoms  caused  by  the 
passage  of  uric  acid  gravel  receive  marked  and  speedy  relief  from  alka- 
line solutions,  but  I  have  never  been  successful  in  removing  by  such 
means  the  signs  of  a  stationary  renal  concretion.  In  cases  where  un- 
mistakable symptoms  of  stone  in  the  kidney  have  been  associated  with 
highly  acid  urine  and  the  habitual  passage  of  uric  acid  gravel,  so  that 
the  nature  of  the  concretion  was  scarcely  more  doubtful  than  its  position, 
I  have  kept  the  urine  alkaline  with  potash  for  periods  varying  from  two 
to  five  months.  Under  such  treatment,  without  injury  to  the  general 
health,  the  local  symptoms  have  mitigated,  but  they  have  never  disap- 
peared. The  benefit  has  declared  itself  in  a  diminution  of  pain,  with  in- 
creased tolerance  of  rough  locomotion  and  improved  power  of  walking. 
A  lady  whose  walks  had  been  restricted  to  a  mile  a  day  by  pain  in  the 
loin,  leg,  and  foot,  attributed  to  a  concretion  of  uric  acid  in  the  left  kid- 
ney, became,  under  alkalies,  able  to  walk  four  miles  with  no  more  in- 
convenience, and  she  subsequently  endured  much  rough  travelling  with 
little  annoyance,  which  it  was  thought  she  could  not  have  done  previous 
to  the  treatment.  Beyond  such  alleviation  of  symptoms  my  success  in 
the  solution  of  calculi  has  not  gone. 

To  sum  up,  the  solution  of  stones  whether  in  the  bladder  or  kidney, 
is  not  yet  within  the  range  of  practical  medicine.  Lithia  is  not  well 
borne;  potash  out  of  the  body  in  the  most  favorable  circumstances  acts 
slowly;  within  the  body,  there  is  the  uncertainty  as  to  the  nature  of  the 
stone,  and  the  suitability  of  alkaline  treatment.  When  in  the  bladder, 
any  such  tedious  and  worse  than  uncertain  method  can  never  be  opposed 
to  the  operation  of  lithotrity,  though  when  it  is  impracticable,  or  as  an 
adjunct  to  it,  acid  injections  may  find  the  use  which  has  been  assigned  to 
them.  As  to  the  kidney,  enough  has  been  said  to  show  that  no  methods 
which  have  as  yet  been  tried  are  substantially  effective;  if  the  solution  of 
calculi  is  ever  to  be  accomplished  it  must  be  from  a  new  departure. 


OHAPTEE  XY. 

MISPLACEMENT,  DISPLACEMENT,  AND  MOBILITY  OF 
THE  KIDNEY. 

MiSPLACEMEJS'T. 

Before  considering  the  movable  kidney,  which  may  either  be  con- 
genital or  acquired,  a  word  may  be  said  about  congenital  misplacement 
of  the  organ  so  far  as  this  condition  is  capable  of  clinical  recognition  or 
has  practical  importance.  The  common  horseshoe  fusion  of  the  two 
kidneys  hardly  comes  within  this  description,  but  one  kidney  has  often 
been  found  to  be  misplaced  downwards,  either  upon  the  lower  part  of 
yertebral  column  on  its  own  or  the  oj)posite  side,  often  upon  the  sacro- 
iliac promontory  or  the  sacro-iliac  synchondrosis.  The  organ  has  been 
found  in  one  of  the  iliac  fosste,  or  partially  or  entirely  within  the  j)elvis. 
It  appears  that  the  development  of  the  renal  structures  commences  in 
front  of  the  bifurcation  of  the  aorta,  and  that  the  ordinary  misplace- 
ment of  one  of  these  organs  is  due  to  its  retention  in  or  near  its 
original  situation.  The  misplaced  organ  usually  presents  itself  as  a 
post-mortem  surprise,  though  its  situation  is  often  such  that  it  could 
not  fail  to  have  been  felt  as  an  abdominal  tumor  had  there  been  any 
symptoms  which  suggested  palpation  of  the  abdomen.  The  kidney  thus 
out  of  place  has  indeed  been  so  recognized,  and  in  one  instance  extirpated 
in  circumstances  which  will  be  presently  referred  to.  A  gentleman, 
aged  45,'  whose  case  is  related  by  Mr.  Durham,  had  an  attack  of  fever, 
during  convalescence  from  which  a  swelling  was  noticed  in  tlie  hypogas- 
tric organ,  somewhat  to  the  left  of  the  median  line ;  it  Avas  oval,  elastic 
and  fixed,  not  nodulated,  nor  did  it  present  any  distinct  elevations  or 
depressions.  j\Ianipulation  caused  disagreeable  sensations,  but  not  acute 
pain.  No  conclusion  Avas  arrived  at  as  to  the  nature  of  the  tumor.  Five 
years  later  it  was  exposed,  ^;o.s^  mortem,  and  found  to  be  the  left  kidney, 
which  was  situated  over  the  sacro-iliac  synchondrosis  and  extended  some- 
what on  to  the  promontory  of  the  sacrum,  and  also  by  its  lower  part  into 
the  true  pelvis.  The  colon  formed  no  sigmoid  flexure  in  the  left  iliac 
fossa  but  passed  across  the  median  line,  and  the  commencement  of  the 
rectum  was  on  the  right  side  of  the  sacrum.  The  kidney  was  partially 
divided  into  three  lobes.  Four  ureters  left  it,  which  shortly  united  into 
one  ;  there  was  no  distinct  liilum,  and  consequently  not  the  characteris- 
tic kidney  shape.  The  organ  received  three  arteries,  the  largest  from 
the  aorta  near  the  bifurcation,  a  branch  from  the  right  common  iliac, 
and  one  from  the  left  internal  iliac.  The  supra-renal  capsule  was  in  its 
normal  position. 

'Paper  bv  Mr.  Durham  "On  Misplacement  and  Mobility  of  the  Kidneys  " 
Guy's  Hospital  Reports,  186U,  p.  408. 


MISPLACEMENT    AND    MOBILITY    OF    THE    KIDNEY.  205 

The  misplaced  kidney  has  been  known  to  form  an  impediment  to 
labor,  as  in  one  instance  quoted  by  Rayer,  in  which  it  was  found  after 
death  deeply  situated  on  the  inner  side  of  the  psoas  muscle. '  Two  chil- 
dren had  been  borne  ;  with  the  delivery  of  each  a  tumor  was  recognized 
on  the  left  side  of  the  pelvis,  which  became  painful  with  each  contrac- 
tion of  the  uterus  and  retarded  the  passage  of  the  head. 

Congenital  misplacement  of  the  kidney  is  in  a  considerable  majority 
of  instances  of  the  left,  and  in  the  male  sex  ;  acquired  dislocation  or 
mobility  chiefly  alfects  females,  as  will  presently  be  seen,  and  the  right 
side. 

Displacement  and  Mobility. 

The  kidney  is  apt  to  be  displaced  or  to  become  movable  as  the  result 
either  of  acquired  or  congenital  states.  It  is  sometimes  completely  sur- 
rounded by  peritoneum,  the  folds  of  which  meet  behind,  like  those  of 
the  mesentery,  forming  what  has  been  termed  a  mesonepliron,  which  may 
allow  so  much  liberty  of  movement  that  the  organ  may  be  immediately 
beneath  the  abdominal  wall  or  elsewhere,  far  from  its  proper  position. 
In  other  circumstances  the  kidney  becomes  loosened  in  its  bed,  so  as  to 
be  capable  of  being  moved  within  it,  but  within  which  its  movements  are 
limited. 

It  is  ordinarily  covered  by  the  peritoneum,  but  not  embraced  by  it, 
nor,  putting  aside  a  long  anchorage  from  the  hilum,  is  the  organ  fixed 
in  the  interval  in  which  it  lies  otherwise  tlian  by  the  cohesion  of  the 
areolar  tissue  around  it.  A  temporary  increase  in  the  size  of  the  gland 
can  easily  expand  the  inclosure  which  it  occupies,  so  that  this,  when  the 
enlargement  has  subsided,  is  too  wide  for  the  structure  within ;  or  any 
force  brought  to  bear  upon  the  organ  may  cause  it  to  split  its  encase- 
ment in  one  direction  ot  another,  and  thus  come  to  occupy  a  cavity 
which  is  too  large  for  it,  and  within  the  limits  of  which  it  can  move. 
In  the  first  of  these  circumstances  the  kidney  may  float ;  in  the  second, 
without  floating,  may  become  movable.  The  movable  and  the  floating 
kidney  may  be  distinct  in  origin  and  nature,  the  movable  kidney  an  ac- 
quired, the  floating  a  congenital  state,  or  they  may  be  merely  difiierent 
degrees  of  the  same  condition  :  the  peritoneum  may  become  loose  enough 
to  enfold  the  kidney  and  meet  behind  it,  much  as  though  the  mesone- 
phron  had  been  an  original  structure. 

The  displacements  of  the  kidney  thus  described  have  no  tendency  in 
themselves  to  cause  death,  and  are  far  more  often  met  with  during  life 
than  afterwards ;  nevertheless  they  have  been  exposed  with  sufficient 
frequency  to  give  a  pathological  foundation  to  our  clinical  knowledge. 
I  believe  that  acquired  mobility  of  the  kidney  is  more  common  tlian  it 
is  generally  supposed  to  be.  I  have  notes  of  eleven  cases  of  it  Avhich  I 
have  seen  during  the  last  five  years. 

The  movable  kidney  is  usually  found  in  women,  and  on  the  right 
side.  Eoberts  estimated  that  of  70  cases  Gl  occurred  in  women,  9  in 
men  ;  Ebstein,  that  of  96  cases  82  were  in  females,  14  in  males.  To 
these  I  may  add  12  cases  of  my  own,  as  yet  unpublished,  of  Avliich  the 
subjects  were  females  in  10  cases,  males  in  2.  As  to  age,  the  disorder  is 
exceedingly  rare  in  childhood  ;  the  earliest  instance  I  have  seen  was  in  a 
girl  of  10,  in  which  mobility  was  associated  with,  probably,  congenital 
displacement.     Instances  have  been  recorded  at  the  ages  of  8,  7,  and  G 

'  Rayer,  loc.  cit.  vol.  iii.  p.  774. 


206  MISPLACEMENT    AND    MOBILITY    OF    THE    KIDNEY. 

years.  In  a  large  majority  of  case^  the  peculiarity  presents  itself  in 
early  adult  and  middle  life,  coincidently  with  the  j^eriod  of  child-bear- 
ing, and  the  frequency  of  accidental  violence. 

It  has  been  said  that  the  subjects  of  the  movable  kidney  are  always 
thin,  a  statement  by  no  means  consistent  with  my  own  experience.  I 
have  seen  it  most  often  in  women  with  large,  loose  abdomens,  often  in- 
clined to  corpulency. 

With  regard  to  the  side  affected  Ebstein — to  quote  his  enumeration 
as  the  latest  and  largest — found  that  of  91  cases,  the  right  kidney  was 
affected  in  05,  the  left  in  14,  both  in  1^.  Among  the  12  instances  re- 
ferred to,  10  belonged  to  the  right  kidney,  2  to  the  left. 

The  condition  is  usually  acquired  after  birth,  though  sometimes  the 
result  of  a  congenital  peculiarity  of  the  peritoneum.  Mr.  Durham'  re- 
ports a  case  in  which  this  membrane  presented  an  abnormal  arrange- 
ment which  was  associated  with  malposition  of  the  colon.  In  this  in- 
stance the  affected  kidney,  which  was  the  left,  could  Ije  made,  after 
death,  to  ya&s  from  its  proper  position  into  the  left  iliac  fossa,  and  also 
across  the  spine,  somewhat  to  its  right  side. 

It  once  happened  to  me  to  observe  in  the  course  of  the  post-mortem 
examination  of  a  person  in  whom  no  renal  symptoms  had  attracted  at- 
tention that  the  layers  of  peritoneum  met  behind  one  kidney,  forming  a 
complete  mesonephron  about  an  inch  and  a  half  long,  to  the  extent  of 
which  the  organ  enjoyed  free  play.  This  arrangement,  of  which  several 
similar  examples  have  been  recorded,  was  probably  congenital.  As  to 
the  acquired  conditions,  the  organ  has  been  known  to  have  been  dis- 
placed downwards,  in  connection  with  a  hernia  which  involved  the 
caecum,  possibly  dragged  down  by  the  descending  bowel.  Usually  the 
state  found  is  mere  looseness  of  the  peritoneal  covering  by  which,  to- 
gether with  the  structures  which  enter  the  liilum,  the  kidney  is  held  in 
place.  The  amount  of  mobility  varies  much;  the  gland  usually  slipping 
down  for  an  inch  or  two  under  pressure  or  change  of  posture,  some- 
times moving,  as  in  a  case  referred  to  in  the  "Pathological  Transac- 
tions," ^  within  a  circle  having  a  diameter  of  eight  or  nine  inches.  The 
kidney  itself  has  in  most  cases  been  found  to  be  healthy,  though  some- 
times its  condition  and  environment  show  changes  which  account  for  its' 
peculiarity,  and  sometimes  alterations  which  are  subsequent,  and  possi- 
bly consequent,  upon  it.  A  deticiency  of  the  circumrenal  fat  has  been 
often  noticed,  and  the  mobility  of  the  organ  found  to  follow  upon  rapid 
emaciation.  An  instance  in  which  the  organ  had  probably  thus  become 
loosened  in  its  bed  by  losing  its  packing  has  been  reported  by  Dr. 
Jago,3  and  others  of  the  same  sort  have  been  recorded. 

Mobility  of  the  kidney  has  been  associated  with  p3'elitis,  as  in  an  in- 
stance within  my  own  experience  to  which  I  shall  presently  refer. 

Dr.  Sawyer'  relates  the  case  of  a  woman  W'ho  died  at  the  age  of 
thirty-five  Avith  svmptoms  of  a  right  movable  kidney  and  pyelitis.  She 
had  had  seven  children,  and  for  six  years  had  had  pain  and  frequency 
in  passing  urine.     Latterly  the  urine  had  contained  much  pus,  evidently 

'  Durham,  Ony's  Hospital  Reports,  1860,  vol.  vi.  p.  413. 

'  Report  of  Committee  on  Displaced,  Movable,  or  Floating  Kidneys,  Path. 
Trans,  vol.  xxvii.  p.  467. 

3  Medical  Times,  September,  1872,  p.  329. 

■*  Paper  on  "  Floating  Kidney,"  by  J.  Sawj^er,  M.B.,  Birmingham  Medical  Re- 
view,  1872,  vol.  i.  p.  120.  See  also  report  by  Dr.  Hickenbotham,  Brit.  Med. 
Journ.  December  24th.  1870. 


MISPLACEMENT    AND    MOBILITY    OF    THE    KIDNEY.  207 

of  renal  origin.  She  died  of  acute  peritonitis.  The  right  kidney  which 
lay  between  the  umbilicus  and  the  anterior  superior  spine  of  the  ilium 
was  riddled  witli  abscesses,  and  the  ureter  dilated  and  thickened.  We 
have  no  evidence  of  the  cause  of  the  pyelitis  in  this  case,  or  whether  it 
preceded  or  followed  the  mobility,  but  the  fact  of  the  association  is  of 
interest.  The  same  concurrence  is  to  be  seen  with  hydronephrosis,  as  in 
one  instance  related  by  M.  Fritz.'  A  woman  of  the  age  of  thirty-three, 
who  had  long  had  pains  in  the  right  iliac  fossa,  w^as  found  to  i)resent  an 
oval  tumor  in  tliis  region  which  had  the  character  of  hydronephrosis. 
The  tumor,  which  extended  from  the  lumbar  to  the  umbilical  region, 
was  movable  in  all  directions.  After  a  time  a  calculus  was  passed,  and 
the  tumor  much  diminished,  still  remaining  movable. 

Another  instance  of  a  similar  association  is  related  in  the  same  paper 
from  the  experience  of  M.  Urag.  A  woman  wdio  was  the  subject  of 
bronchitis  was  found  to  present  a  reniform  tumor  in  the  abdomen  below 
the  anterior  border  of  tlie  right  lobe  of  the  liver.  This  moved  with  re- 
spiration, and  could  be  displaced  towards  the  median  line,  towards  the 
right  lumbar  region  and  slightly  downwards.  Manipulation  caused  con- 
siderable pain.  After  death  it  was  found  that  the  tumor  was  the  right 
kidney,  Avhich  was  attached  by  old  adhesions  to  the  liver,  the  gall-blad- 
der, and  the  transverse  colon.  The  organ  was  hydronephrotic,  the 
ureter  being  occluded,  inconsequence  of  ^'engorgement"  of  the  posterior 
wall  of  the  uterus.  In  the  latter  case  the  condition  was  complicated  by 
the  adhesions  which  occurred  in  the  course  of  the  disease  ;  but  in  both 
it  is  probable  that  the  essential  cause  of  the  mobility  was  the  alternation 
of  bulk  which  the  condition  of  hydronephrosis  generally  involves. 

Whether  a-soeiated  with  pyelitis  or  hydronephrosis,  there  is  not  in- 
frequently a  history  of  calculus  or  gravel  in  connection  with  the  movable 
kidney — accidents  which  particularly  tend,  to  cause  the  variation  of  bulk 
which  are  so  ajit  to  loosen  its  attachments. 

To  complete  the  morbid  anatomy  of  the  condition  before  further  dis- 
cussing its  mode  of  origin,  the  kidney,  though  usually  healthy,  has  been 
found  to  have  become  affected  in  various  ways,  either  consequently  upon 
its  mobility  or  independently  of  it.  The  most  common  change  is  peri- 
nephritis, as  indicated  by  peritoneal  thickening,  and  occasionally  by 
adhesions  to  the  neighboring  organs— especially  the  liver.  The  fre- 
quency of  pyelitis  in  this  relation  suggests  that  the  inflammatory  state 
may  occur  not  only  antecedently,  but  also  as  a  consequence  of  the  mobil- 
ity by  means  of  the  constriction  of  the  renal  outlet  which  the  shifting 
must  often  involve.  The  displaced  or  movable  kidney  is  not  thereby 
exempted  from  other  chances  of  disease.  It  has  been  found  to  be  granu- 
lar, as  in  an  instance  related  by  Dr.  Coats.  ° 

The  causes  of  the  condition  are  in  great  part  explained  by  its  morbid 
anatomy.  Loss  of  bulk,  whether  in  or  about  the  kidney,  whether  the 
escape  of  an  accumulation  from  the  pelvis  Avhereby  the  kidney  shrinks 
so  as  no  longer  to  fill  its  bed,  or  loss  of  the  surrounding  fat  so  that  its 
bed  becomes  too  large  for  it,  has  been  sufliiciently  dwelt  upon  in  con- 
nection with  its  origin.  It  remains  to  add  what  is  needed  to  make  the 
tale  complete.  The  kidney  appears  to  be  often  displaced  by  external 
pressure  or  violence.     The  leading  facts  in  the  distribution  of  the  pecu- 

'  Paper  by  M.  Fritz  on  "  Floating  Kidneys,"  Archives  Generales  de  Medecine, 
1859.  A'ol.  ii.  p.  168. 

Path.  Trans.,  vol.  xxvii.  p.  469. 


208 


MISPLACEMENT    AND    MOBILITY    OF    THE    KIDNEY 


larity.  its  frequency  with  women,  and  on  the  right  side,  may  point  to 
intiuence  of  pregnancy,  of  tight  lacing,  and  of  the  pressure  of  the  liver. 
It  has  been  observed  that  movable  kidneys  are  most  often  found  in  wo- 
men who  have  borne  children,  and  that  after  delivery  the  abdominal 
muscles  are  lax,  and  the  viscera  comparatively  unsupported.  Of  twelve 
cases  of  movable  kidney  under  my  own  observation,  the  subjects  of  nine 
were  women  who  had  had  children,  though  one  of  these  attributed  her 
disorder  not  to  pregnancy  but  to  severe  and  repeated  exertion  in  lifting 
a  sick  husband,  and  another  to  a  fall  upon  tl>e  right  lumbar  region. 


Fig.  1.— Misplaced  left  kidney  with  two       Fig.  :i.— Movable  right  kidney  in  a  man. 
faecal  masses . 


Fig.  .3.— Movable  right  kidney  in  a  woman.    Fig.  4.— ^lovable  riijlit  kidney  in  a  woman 


One  of  my  patients  became  aware  of  the  mischief  upon  recovering 
from  chloroform,  Avhich  had  been  given  during  labor  ;  another  at- 
tributed it  to  violence  used  in  the  extraction  of  the  placenta  by  an  in- 
ebriated accoucheur.  The  condition  had  been  somewhat  doubtfully 
attributed  in  the  same  sexto  a  hyper.Tmic  swelling  of  the  organ  supposed 
to  occur  at  each  menstrual  period  and  subside  with  it.  Tight  lacing  by 
which  the  liver  is  pressed  down  upon  the  right  kidney  has  been  assigned 
as  a  cause  of  its  becoming  loosened  and  displaced;  and  the  same  result 
has  been  with  more  certainty  traced  to  strains  and  falls  and  other  violent 


MISPLACEMENT    AND    MOBILITY    OF    THE    KIDNEY. 


209 


injuries.  It  has  been  said,  though  my  own  personal  experience  scarcely 
bears  out  the  statement,  that  movable  kidneys  are  proportionately  more 
often  met  with  among  women  of  the  working  class  than  amongst  those 
in  easy  circumstances,  with  whom  tight  lacing  is  more  common. 

A  gentleman  under  my  care,  whose  case  will  be  further  referred  to, 
attributes  the  peculiarity  which  affects  the  right  kidney  to  repeated  falls 
in  hunting.  An  instance  is  related '  in  which  the  left  kidney  became 
thus  movable  inconsequence  of  a  fall  upon  the  ice,  and  another  in  wliich 
both  became  so  after  a  fall  from  a  horse.  A  laborer  ^  over  whose  loins  a 
cart  passed  was  found  by  Dr.  Yeo  to  present  afterwards  the  signs  of 
movable  kidney. 

With  regard  to  the  clinical  aspect  of  movable  and  displaced  kidneys, 
the  latter,  so  far  as  congenital  malposition  is  concerned,  need  no  further 
notice  than  has  already  been  given  them.  Movable  or  floating  kidneys, 
however,  have  much  importance  from  this  point  of  view.  They  are  to  be 


Fig.  5.— Right  kidney  extensively  movable. 


Fig.  6.— Right  kidney  extensively  movable. 


recognized  by  the  presentation  of  a  tumor  of  renal  size  and  shape  in  a 
position  not  1)elonging  to  the  kidney,  from  which,  under  pressure,  it 
withdraws  itself  in  the  direction  of  the  proper  renal  region.  The  pecu- 
liar slipping  of  the  movable  kidney  under  the  influences  of  pressure  and 
position,  at  once  distinguishes  it  from  every  other  abdominal  tumor;  it 
moves  like  the  testicle  in  the  scrotum  or  a  pea  in  its  pod.  The  organ 
emerges  from  the  depths  of  the  liypochondrium,  commonly  the  right,  to 
present  itself  as  a  tumor  tangible  from  the  front  or  lateral  aspect  of  the 
abdomen.  The  position  of  the  tumor  has  a  wide  range:  it  nuiy  not  de- 
scend further  than  as  if  the  lower  end  of  the  kidney  protruded  from 
under  the  edge  of  the  ribs,  or  the  organ  may  pass  as  low  as  the  umbili- 
cus or  even  into  the  iliac  fossa,  and  occupy  almost  any  i)art  of  the  S})ace 
between  the  lateral  limit  of  the  trunk  and  the  median  line,  which 
boundary,  indeed,  is  sometimes  partially  crossed  by  the  erratic  mass. 


14 


'  Roberts,  loc.  cit.  3d  edition,  p.  014. 
^Brit.  Med.  Journ.,  June  6th,  18y4,  p.  744. 


210  MISPLACEMENT    AND    MOBILITV    OF    THE    KIDNEY. 

The  lump  suddenly  presents  itself  from  under  the  ribs  from  the  effect 
of  bodily  movement — the  patient  possibly  turning  on  the  side  on  which 
the  movable  kidney  is  not — or  of  deep  inspiration,  perhaps  undertaken 
with  the  purpose  of  displaying  the  condition.  The  rounded  and  reniform 
mass  may  then  be  more  or  less  grasped,  and  made  by  directed  pressure 
to  hastily  withdraw  itself  in  the  direction  whence  it  came,  gliding  at 
once  out  of  reach,  giving  to  the  fingers  a  sensation  as  if  it  were  slippery. 
When  the  organ  descends,  its  absence  can  be  detected  from  the  lumbar 
region  by  hollowness  and  comparative  resonance.  The  displaced  kidney 
may  be  near  the  surface,  though  usually  not  so  superficial  but  that  bowel 
resonance  can  be  detected  over  it.  The  pulsation  of  the  renal  artery  has 
been  felt,  though  the  mass  is  seldom  sufficiently  suj^erficial  to  allow  of 
this.  Sometimes  it  is  very  deep,  only  to  be  reached  by  somewhat  forci- 
ble palpation,  and  even  may  be  distinctly  recognizable  only  when  the 
abdominal  resistance  is  overcome  with  chloroform.  Pressure  on  the  or- 
gan usually  gives  rise  to  a  sickening  sensation. 

The  shifting  may  be  quite  or  nearly  without  discomfort,  or  may  be 
attended  with  much  pain  and  intestinal  or  nervous  disturbance,  symp- 
toms which  are  probably  largely  due  to  the  tension  or  forced  flexure  of  the 
nerves  which  enter  the  hilum. 

The  pain  is  often  described  as  of  a  dragging  character.  It  chiefly 
accompanies  displacement  of  the  organs,  though  in  some  cases  always 
present  more  or  less.  It  is  aggravated  by  movement  and  relieved  by 
lying  down.  It  stretches  from  the  lumbar  region  to  the  tumor,  which 
is  apt  to  become  tender,  and  often  shoots  in  various  directions,  into  the 
testicle  or  labium  and  down  the  thigh.  I  have  known  a  patient  so  suf- 
fering to  have  severe  pains  of  a  neuralgic  character  in  parts  of  the  body 
not  locally  connected  Avith  the  affected  part. 

The  pain  of  the  movable  kidney  has  been  observed,  as  with  a  patient 
of  my  own,  to  become  aggravated  at  the  monthly  periods,  and  the  dis- 
placed organ  thought  to  swell.  A  peculiarity  of  the  disorder  is  the  oc- 
currence at  irregular  intervals,  and  often  without  any  obvious  cause,  of 
severe  attacks  of  pain  Avith  constitutional  disturbance,  not  unlike  fits  of 
renal  colic.  The  displaced  organ  swells  and  becomes  exquisitely  tender, 
and  cannot  be  replaced.  There  is  intense  pain  in  its  neighborhood,  to- 
gether with  shivering,  sickness,  and  prostration.  "With  a  lady  under  my 
care,  the  attacks  recurred  about  every  five  or  six  days,  each  lasting  ten  or 
twelve  hours.  -The  jmin  was  described  as  ver}'  severe,  passing  through 
the  abdomen  under  the  liver  to  the  spine.  These  were  attended  with 
vomiting  and  extreme  prostration.  They  subsided  under  the  influences  of 
morphia  and  rest  in  bed.  These  seizures  have  been  thought  to  depend 
upon  retention  of  urine  in  the  pelvis,  owing  to  some  twist  or  compression 
of  the  renal  outlet,  but  the  evidence  of  this  is  incomplete,  and  indeed  with 
the  remarkable  toleration  of  obstructive  suppression  when  it  affects  only 
one  kidney,  we  can  scarcely  assign  the  severe  and  sudden  symptoms  wliicli 
have  been  described  to  this  origin.  It  has  been  supposed  with  more 
probability  that  a  sharp  bend  or  twist  of  the  renal  vein,  with  consequent 
congestion  and  swelling  of  the  organ,  is  more  particularly  concerned  in  the 
production  of  these  paroxysms;  at  the  same  time  it  must  be  allowed 
that  their  symptoms,  apart  from  the  swelling,  tlie  pain,  vomiting,  and 
prostration,  show  at  least  that  the  nerves  are  closely  implicated  in  the 
passing  disorder,  even  if  not  its  primary  cause  in  some  mechanical  man- 
ner connected  Avith  dislocation. 


MISPLACEMENT    AND    MOBILITY    OF    THE    KIDNEY.  211 

Vesical  irritation  and  frequency  have  occasionally'  been  noticed.  A 
gentleman,  who  applied  to  me  with  a  movable  kidney,  had,  at  the  time 
of  its  appearance,  symptoms  which  were  attributed  to  cystitis.  When 
I  saw  him  some  weeks  afterwards,  I  found  that  the  urine  was  phosphatic, 
but  free  from  pus;  I  presumed  that  the  irritation  might  have  been  purely 
of  nervous  origin.  Various  forms  of  bowel  disturbance  are  frequently 
noticed  in  connection  with  the  condition.  A  gentleman  under  my  no- 
tice who  had  a  movable  right  kidney,  found  that  occasional  diarrhoea 
was  the  chief  trouble  it  caused.  Tlie  diarrhoea  was  connected  in  sensa- 
tion with  the  movable  organ,  and  was  always  brought  on  wlien,  by  in- 
creased bodily  movement  or  mental  excitement,  the  pain  in  it  was  made 
worse.  In  a  case  mentioned  by  Dr.  Roberts,  also  of  a  movable  right 
kidney  in  a  man,  there  was  much  irritability  of  the  bowels,  associated 
with  dragging  pain  in  the  situation  of  the  kidney  and  ascending  colon. 
Constipation  and  faecal  accumulation  have  also  been  found.  A  girl  of 
10  years  old  under  my  care  had  a  misplaced  kidney,  which  lay  near  the 
surface  of  the  belly  to  the  left  of  the  umbilicus.  She  had  at  the  same 
time  a  number  of  superficial  lumps  in  the  abdomen,  which  were  re- 
moved by  purgatives,  and  no  doubt  were  f«cal.  An  instance  is  recorded 
by  Dr.  Johnson^  in  which  accumulation  of  the  same  nature  had  simi- 
larly resulted. 

A  displaced  right  kidney  has  been  known,  as  in  an  instance  recorded 
by  Girard,3  to  compress  the  vena  cava  and  cause  a3dema  of  the  right 
lower  limb.  Jaundice  has  been  produced  by  the  compression  of  the 
common  bile-duct  by  a  dislocated  kidney,  which  was  in  contact  with  the 
transverse  fissure  of  the  liver*  and  adherent  to  the  duodenum. 

The  kidney  may  be  diseased  independently  of  its  displacement,  but, 
putting  this  aside,  the  only  urinary  changes  proper  to  this  condition  are 
such  as  give  evidence  of  pyelitis.  When  this  complication  is  not  present 
the  urine  is  natural.  Evidences  of  pyelitis,  possibly  only  microscopic, 
scales  of  epithelium,  presumably  from  the  pelvis,  and  perhaps  a  few 
pus-globules,  are  found  more  often  than  not  with  such  cases,  while  in 
some  the  urine  is  abundantly  purulent,  showing  a  high  degree  of  the 
same  inflammatory  state.  It  is  clear  from  what  has  been  already  stated 
that  some  conditions  associated  Avith  pyelitis  may  precede  and  cause  the 
mobility,  but  it  is  no  less  probable  that  the  necessary  distortion  of  the 
pelvic  outlet  may  in  some  cases  prevent  the  free  escape  of  urine,  and 
thus  produce  results  due  to  its  retention. 

The  diagnosis  of  the  condition  presents  little  difficulty  ;  the  peculiar 
mobility  is  pathognomonic.  A  movable  kidney  has  been  mistaken  for 
the  spleen,  and  frequently  for  a  morbid  growth  within  the  abdomen. 
Women  who  have  had  them  have  been  known  to  persist  that  their  move- 
ments were  those  of  a  foetus  i)i  utero. 

As  the  disease  has  little  tendency  either  to  shorten  life  or  to  get  well, 
its  duration  is  absolutely  indefinite.  Among  11  cases  under  my  own  ob- 
servation, where  the  date  of  beginning  was  noted,  was  1  in  which  the 
condition  had  lasted  for  thirteen  years,  1  for  six,  3  for  five.     Dr.  Jago " 


*  jritz,  Archives  Generales  de  Medecine,  1859,  vol.  xiv.  p.  171. 
^  Med.  Times,  October,  1859,  p.  426. 

^  Journal  Hebdomadaire  des  Proqres  des  Sciences  Medicales,  1836,  vol.  iv.  p. 
445. 

*  Brit.  Med.  Journ.,  January  29th,  1876. 
5  Med.  Times,  September,  1872,  p.  328. 


212  MISPLACEMENT    AND    MOBILITY    OF    THE    KIDNEY. 

mentions  one  instance  in  wliicli  it  had  been  present  for  twenty-three 
years. 

Death  usually  occurs  from  some  cause  unconnected  with  the  state  of 
the  kidney,  though  where  it  has  been  associated  with  pyelitis  a  fatal 
issue  has  been  brought  about  by  this  complication.  A  woman'  under 
the  care  of  Dr.  Hickenbotham,  whose  case  has  already  been  referred  to, 
had  a  floating  right  kidney,  together  with  pyelitis,  as  evinced  by  the 
passing  of  pus,  blood,  and  phosphates  with  the  urine.  Fourteen  days 
before  her  death  she  was  seized  with  pain  in  the  movable  kidney,  which 
she  had  not  had  before,  followed  by  symptoms  of  peritonitis.  It  was 
found  that,  in  addition  to  general  inflammation  of  the  peritoneum,  the 
right  kidney  was  riddled  with  abscesses,  and  its  ureter  dilated  and 
thickened.  The  peritonitis  had  probably  been  produced  by  the  renal 
suppuration,  that  by  the  pyelitis.  No  cause  apjjears  for  the  j^yelitis  be- 
sides the  displacement. 

The  medical  treatment  of  the  condition  essentially  consists  in  the 
replacement  of  the  organ,  its  retention  in  its  proper  position,  and  the 
relief  of  the  pain  to  which  its  displacement  gives  rise.  A  simjile  and 
often  sufficient  measure  of  relief  is  the  recumbent  posture.  The  avoid- 
ance of  riding  on  horseback,  and  all  rough  exercises  and  modes  of  loco- 
motion, and  straining  at  stool,  is  no  less  obvious.  A  woman,  whose 
case  is  mentioned  by  Dr.  Hare,^  lost  her  symptoms  almost  entirely  under 
the  influence,  as  was  thought,  of  two  successive  pregnancies,  the  enlarged 
uterus  supplying  the  needed  upward  pressure.  Artificial  sup2:)ort  by 
means  of  a  belt  or  truss  has  often  been  used  with  advantage.-  For  a 
lady  who  suffered  from  severe  and  frequent  paroxysms  of  pain,  con- 
nected with  a  movable  right  kidney,  I  had  a  truss  constructed  with  a 
powerful  spring,  of  which  one  end  rested  od  the  spine,  the  other  pressed 
a  conical  pad,  with  a  spiral  spring,  deep  into  the  right  hypochondrium. 
This  instrument  proved  so  effective  that  whereas  the  attacks  formerly 
recurred  every  five  or  six  days,  after  its  application  the  lady  passed  six 
months  with  only  one,  which  had  been  brought  on  by  exceptional  exer- 
tion. The  objection  to  a  truss  is  the  inconvenience  of  the  necessary 
pressure. 

A  less  uncomfortable  measure,  but  one  which  is  found  in  some  cases 
to  suffice,  is  a  broad  elastic  belt,  fitted  to  the  shape,  with  a  firm  pad 
upon  the  hypochondrium.  I  have  at  present  five  ]')atients  who  wear 
with  advantage  renal  supports,  three  trusses,  two  bandages. 

Dr.  De  Mussy  arranged,  with  benefit,  that  a  lady,  whose  right  kidney 
had  become  loose,  should  have  an  action  of  the  bowels  every  evening, 
and  before  rising  in  the  morning — that  is,  before  the  organ  had  become 
displaced  by  movement — should  slip  upwards  over  the  lower  extremities 
an  elastic  bandage,  to  which  a  horse-hair  pad  was  so  fixed  as  to  press  in 
front  of  the  affected  lumbar  region. 

The  urgent  paroxysms  of  pain  and  vomiting  which  are  sometimes 
attributed  to  strangulation  of  the  ureter,  but  which  are  more  probably 
due  to  stretching  or  twisting  of  the  nerves  or  veins,  are  to  be  treated 
with  absolute  rest  and  morphia,  the  replacement  of  the  organ  when  this 
can  be  accomplished  without  violence,  and  such  measures  as  leeching 
and  fomentation,  should  symptoms  of  local  peritonitis  present  them- 
selves.    The  attacks  usually  appear  to  be  of  brief  duration. 

'  Paper  by  Dr.  Sawyer,  Birmingham  Med.  Review,  vol.  i.  p.  130. 
"^  Med.  Times,  January,  1853,  p.  112. 


MISPLACEMENT    AND    MOBILITY    OF    THE    KIDNEY.  213 

Importance  must  be  attributed  to  the  regulation  of  the  bowels;  while 
the  anjemic,  hyijochondriaeal,  and  neuralgic  conditions  so  common  with 
the  disorder  call  for  ferruginous  medicines  and  others  of  the  tonic  class. 

Pyelitis,  gravel,  or  phosphuria  may  call  for  appropriate  modifica- 
tions of  the  treatment  should  these  complications  present  themselves. 

Regarding  the  movable  kidney,  as  we  must,  not  so  much  as  a  danger 
as  an  inconvenience,  and  an  inconvenience  which  can  be  mitigated  almost 
to  nothing  by  safe  and  jjainless  measures,  it  can  seldom  be  justifiable  to 
risk  life  in  search  of  cure.  Nevertheless,  kidneys  in  this  state  have 
been  removed  often  enough  to  enable  us  to  measure  with  some  accuracy 
the  death-rate  of  the  operation.'  Martin,  of  Berlin,  states  that  he  has 
excised  a  floating  kidney  in  seven  cases,  with  the  result  of  four  cures  and 
three  deaths.  He  always  cut  from  the  front  throilgh  the  peritoneal 
cavity.  The  operation  was  once  performed  by  Meckel,-  also  from 
the  front,  with  a  fatal  result,  and  by  Smith,  of  New  Orleans, 
from  the  loin,  with  a  favorable  one.  Thus  with  nine  excisions  there 
were  four  deaths.  Dr.  Harris,  of  Philadelphia,  in  a  recent  collection  of 
one  hundred  cases  of  extirpation  of  the  kidney,  includes  sixteen  in  which 
floating  kidneys  were  thus  treated.'  Putting  aside  one  in  which  the  re- 
moved organ  was  the  seat  of  sarcoma,  and  the  result  fatal,  there  were 
five  deaths  to  ten  recoveries,  surgical  enterprise  having  thus  provided  a 
considerable  mortality  for  a  disorder  which  of  itself  has  little  or  none. 
A  startling  case  is  reported  by  Dr.  Polk,  of  New  York,  in  which  a  pain- 
ful tumor  in  the  left  iliac  fossa,  which  was  supposed  to  be  what  it  ulti- 
mately proved,  a  misplaced  left  kidney,  was  removed  from  a  young 
woman  in  whom,  as  has  been  ascertained,  the  vagina  and  uterus  were 
absent.*  The  patient  survived  the  operation  for  eleven  days.  It  was 
afterwards  found  that  the  kidney  of  which  she  had  been  thus  dejirived 
was  her  only  one.  No  trace  could  be  found  of  any  structure  correspond- 
ing with  or  belonging  to  the  right  kidney.  It  is  to  be  observed  that  the 
left  kidney  is  more  often  the  subject  of  congenital  misplacement  than 
the  right,  which  fact,  together  with  the  other  congenital  defects  which 
were  found,  might  have  suggested  some  uncertainty  as  to  the  rest  of  the 
organism.  My  personal  experience  of  the  excision  of  movable  kidneys 
amounts  to  my  having  successfully  advised  against  it  in  several  in- 
stances. There  are  conditions  of  suffering  in  which  life  may  be  i3roperly 
endangered  in  search  of  cure.  That  belonging  to  the  movable  kidney 
may  be  one,  but  we  have  to  ask  whether  there  are  not  safer  means  of 
relief  ? 

As  an  apparently  less  formidable  operation  the  movable  organ,  or 
rather  its  capsule,  has  been  fixed  by  sutures  to  a  wound  in  the  loin,  upon 
the  healing  of  which  it  has  been  found  that  the  kidney  has  been  soldered 
to  the  side  by  granulations  and  cicatricial  tissue,  so  as  to  be  no  longer 
movable.  The  present  experience  of  this  operation,  nephroraphy,  as  it 
has  been  termed,  is  small ;  it  has  been  performed  some  seven  times 
without  death,  and  generally  with  benefit. '     It  would  appear  that  sur- 

'  Trans,  of  the  International  Med.  Congress,  vol.  ii.  p.  278. 

^  Paper  by  Mr.  Barker,  Med.-Chir.  Trans,  vols.  Ixiii.  and  Ixiv. 

^  "  Tabular  record  of  100  cases  of  extirpation  of  the  kidneys,"  by  R.  P.  Harris, 
M.D.,  American  Journ.  of  Med.  Science,  July,  1882. 

*  "Case  of  extirpation  of  a  displaced  kidney,"  by  W.  M.  Polk,  M.D.,  New 
York  Med.  Journ.  February  17th.  1883. 

'  Centralblatt  filr  Chirurgie,  July  23d,  1881,  and  July  22d.  1882.  Cases  by  Hahn, 
Esmarch,  and  Kiister.     Paper  by  R.  W.  Wier,  M.D.,  New  Yoi'k  Med.  Journ.  Feb. 


214:  MISPLACEMENT    AND    MOBILITY'    OF    THE    KIDNEY. 

gical  enterprise  in  regard  to  the  movable  kidney  is  more  promising  in 
the  direction  of  fixation  than  removal ;  further  than  this  it  would  not 
become  me  to  express  an  opinion. 

17th,  1883.  Case  by  D.  Newman.  M.D.,  of  Glasgow,  BiHt.  Med.  Journ.  April 
28th,  1883,  p.  831. 


CHAPTER  XYL 

URINAEY    PARAPLEGIA. 

Certai^t  renal  diseases  are  liable  to  produce  paraplegia.  Malignant 
growths  beginning  in  the  kidney  may  encroach  upon  the  vertebrae 
and  eat  into  the  spinal  canal  with  results  as  strongly  pronounced  in 
the  way  of  paralysis  as  are  found  to  follow  fracture  or  dislocation. 
Whether  pus,  which  has  broken  out  of  the  kidney  ever  penetrates  the 
inter- vertebral  foramina  I  do  not  know;  it  seems  not  impossible,  but  I 
have  not  yet  found  an  instance.  Advancing  still  further  into  the  region 
of  hypothesis  we  come  to  the  doctrine  of  Reflex  Urinary  Paraplegia, 
which  Avas  conceived  by  Stanley,  christened  by  Graves,  and  adopted  by 
Brown-Sequard.  The  theory  of  Stanley  was  that  an  irritation  com- 
mencing in  the  kidney  was  conveyed  by  the  nerves  to  the  cord,  which 
itself  underwent  no  change,  but  transmitted  the  irritation  to  the  lower 
limbs,  to  the  impairment  of  their  nervous  function.  The  theory  later 
took  more  definite  shape,  and  met  Avith  much,  and  for  a  time  with  general, 
acceptance.  The  mode  of  operation  was  thought  to  be  clearly  made  out 
by  reasoning  and  experiment,  and  under  the  great  authority  of  Brown- 
Sequard  became  a  part  of  medical  belief.  Anaemia  of  the  cord  was  be- 
lieved to  be  the  essential  change,  this  being  brought  about  by  a  spasm 
of  its  blood-vessels,  and  this  by  an  irritation  carried  to  their  nerves  from 
the  part,  whether  kidney  or  bladder,  which  was  primarily  at  fault.  If  a 
nervous  centre,  it  was  urged,  be  deprived  of  blood,  its  function  is  ab- 
rogated, as  hemiplegia  may  result  from  the  tying  of  a  carotid,  or  para- 
plegia from  ligature  or  compression  of  the  aorta.  So  the  cord,  if 
deprived  of  blood,  though  only  by  vascular  spasm,  may  feasibly  be  sup- 
posed to  cease  to  act  as  a  channel  of  nervous  influence.  This  theory  is 
so  generally  accepted,  at  the  same  time  that  its  application  to  the  kidney 
and  the  existence  of  urinary  paraplegia  as  of  reflex  origin  have  been  so 
gravely  questioned,  that  it  is  necessary  to  look  somewhat  narrowly  at  the 
facts  which  bear  upon  this  part  of  the  question.  Dr.,  now  Sir  W.  Gull, 
in  a  judiciously  sceptical  paper,'  showed  that  in  some  of  the  cases  which 
had  been  accepted  as  of  reflex  paraplegia  the  paralysis  was  not  real,  while 
in  others  it  was  not  reflex,  but  more  probably  connected  with  organic 
disease  of  the  cord,  and  later  still  Dr.  Weir  Mitchell  in  a  no  less  masterly 
criticism*  not  only  enforced  the  incredulity  which  since  Gull's  paper  had 
begun  to  attach  itself  to  the  interpetration  which  Stanley  and  Graves 
had  put  upon  their  cases,  but  also  threw  doubts  upon  the  whole  theory 
of  reflex  jjaralysis.     It  was  urged  that  it  was  highly  improbable  that  a 

'  "  On  paralysis  of  tlie  lower  extremities  consequent  upon  disease  of  the  bladder 
and  kidneys,"  by  W.  Gull,  M.D.,  Guijs  Hospital  Reports,  1861,  vol.  vii.  p.  313. 

'  "  Paralysis  from  peripheral  irritation,"  by  S.  Weir  Mitchell,  M.D.,  New  York 
Med.  Journ.,  1866,  vol.  ii.  p.  321. 


216  URINARY    PARAPLEGIA. 

vasal  spasm  conld  he  steadily  maintained  for  months  or  year?  without 
any  intervals  of  relaxation;  while  supposing  it  to  be  so  maintained  with 
com]ileteness  enough  to  abolish  function  by  want  of  blood  it  was  incon- 
ceivable that  a  tissue  so  mobile  as  the  nervou^  should  not  become  softened 
or  show  otherwise  in  textural  change  some  result  of  the  prolonged  starva- 
tion to  which  it  had  been  subjected.  Softening  of  the  brain  rapidly  fol- 
lows embolic  obstruction,  and  no  less  so  when  the  blood  has  been  cut  off 
bv  ligature,  as  of  the  carotid,  presuming  that  the  collateral  circulation 
is  not  efficient  for  vicarious  duty. 

The  questions  to  be  answered  are  two — first,  whether  there  is  any 
Buch  thing  as  urinary  paraplegia ;  whether  in  any  way,  by  nerves  or 
vessels,  by  any  reflexion,  conveyance,  or  extension  of  disease  apart  from 
the  encroachment  of  a  growth,  paraplegia  is  brought  about  as  a  con- 
sequence of  disease  of  the  urinary  organs; — and  secondly,  Avhether  if 
paraplegia  does  arise  from  this  cause,  whether  it  comes  on  without 
material  change  in  the  cord  by  the  mere  suspension  of  function  which  is 
implied  by  the  term  reflex.  To  find  replies  I  Avill  briefly  review  some  of 
the  evidence  which  has  been  adduced. 

Mr.  Stanley,  in  the  paper  wherein  the  theory  of  urinary  jaaralysis 
was  first  propounded,  related  seven  cases  as  examples.'  In  five  of  these 
the  supposed  cause  of  the  paraplegia  was  that  disseminated  suppuration 
of  the  kidney  which,  as  we  now  know,  is  so  consistently  a  result  of  it. 
Disease  of  the  cord,  paralysis  of  the  bladder,  jDutrefaction  of  urine,  and 
scattered  renal  suppuration  as  the  result  of  absorption,  is  a  morbid  se- 
quence which  is  well  made  out  and  presents  itself  but  too  often.  It  is  at 
least  a  suspicious  circumstance  that  the  particular  form  of  renal  disease 
which  is  credited  with  having  produced  spinal  j)aralysis  is  precisely  that 
which  spinal  paralysis  so  regularly  produces. 

It  is  to  be  presumed,  in  the  absence  of  any  conclusive  evidence  to  the 
contrary,  that  what  Stanley  supposed  to  be  the  cause  was  in  reality  the 
effect,  and  his  deduction,  so  far  as  it  is  based  on  cases  of  this  nature,  cor- 
respondingly mistaken.  That  it  was  so  must  be  clear  to  any  one  who 
reads  the  cases.  Four  of  these  present  much  the  same  outlines:  a  man 
jjerhaps  has  an  injury  to  the  spine  or  he  has  pain  there,  or  without  either 
he  becomes  unable  to  move  his  legs  or  pass  his  water.  He  dies  with  the 
kidney  of  disseminate  suppuration,  but  with  no  disease  of  the  spinal  cord 
which  is  evident  to  the  naked  eye.  Presuming  one  of  the  many  changes 
to  exist  in  the  cord  which  are  effective  for  its  destruction,  though  not 
for  its  disfigurement,  the  sequence  becomes  intelligible  and  consistent 
with  our  daily  experience.  With  the  naked  eye  only  almost  any  change 
confined  to  the  cord  short  of  diffluence  might  escape  notice.  It  is  there- 
fore impossible  to  infer  that  the  cords  in  these  cases  were  healthy  or  the 
paralytic  symptoms  and  the  renal  lesion  otherwise  than  dependent 
upon  spinal  disease.  The  argument  as  api)lied  to  these  of  Stanley's  cases 
is  equally  suited  to  a  large  number  of  similar  ones  related  by  other 
authors,  and  it  may  be  stated  as  a  general  conclusion  that  when  the 
kidney  of  scattered  suppuration  is  concurrent  Avith  paraplegia,  the  dis- 
ease of  the  kidney  is  not  the  cause  but  the  consequence. 

Among  the  other  conditions  regarded  by  Stanley  as  the  cause  of  para- 
plegia Avithout  disease  of  the  cord  is  dilatation  of  the  kidney.  This  was 
exemplified  by  a  case  supplied  by  Burrows  of  a  man  who  for  two  years 

'  "On  irritation  of  tlie  spinal  cord  and  its  nerves  in  connection  with  diseaseof 
the  kidneys,"'  by  E.  Stanley,  Aled.-Chir.  Trans.,  1833,  vol.  xviii.  p.  260. 


URINARY    PARAPLEGIA.  217 

had  had  severe  pain  in  the  spine  and  incontinence  of  urine,  whose  kid- 
neys Avere  found  after  death  with  dihited  and  inflamed  pelves  and  mottled 
structure.  The  spinal  cord  displayed  no  further  evidence  of  disease  than 
much  vascularity  of  the  lumhar  pia  mater  and  an  excess  of  fluid  within 
the  sheath.  During  life  there  had  been  much  tenderness  about  the  sixth 
dorsal  vertebra,  difficulty  of  breathing,  and  the  involuntary  passage  of 
urine  and  faeces.  Presuming  the  vascularity  and  excess  of  fluid  to  indi- 
cate disease  of  the  cord,  as  we  cannot  doubt  that  they  did,  notwith- 
standing that  in  the  absence  of  microscopic  examination  no  other  evi- 
dence of  disease  was  discovered,  the  whole  case  is  clear.  The  condition 
of  kidneys  is  precisely  that  which  must  necessarily  result  from  long 
continued  paralysis  of  the  bladder  with  retention  of  urine,  and  it  needs 
no  further  argument  to  justify  the  obvious  conclusion  that  the  renal 
disorder  was  the  result,  not  the  cause  of  the  spinal. 

Two  cases  are  related  in  which  complete  motor  paralysis,  involving 
the  lower  extremities  and  the  sphincter  together  with  loss  of  sensation 
ensued  upon  gonorrhoea;  one  was  fatal  in  sixteen  hours,  the  other  in 
about  a  fortnight,  with  sloughing.  In  the  more  rapid  case  the  kidneys 
were  found  to  be  merely  congested,  in  the  other  they  contained  abscesses. 
In  the  more  rapid  case  the  cord  was  congested,  in  the  other  it  appeared 
natural.  It  is  scarcely  possible  to  doubt  that  in  both  these  cases  myelitis 
was  present  though  not  disclosed  to  the  naked  eye.  The  comjaleteness 
of  the  paralysis  and  the  sloughing  are  characteristic  of  disease  of  the  cord 
of  definite  and  acute  kind,  while  we  have  the  light  of  several  cases 
minutely  examined  by  Sir  W.  Gull  in  which  paraplegia  ensuant  as  in 
these  instances  ujjon  gonorrhoea  was  found  to  depend  upon  distinct 
inflammatory  change  in  the  cord,  apjjreciable  Avitli  the  microscope,  and 
in  one  instance  not  otherwise.'  Sir  W.  Gull  infers  that  paraplegia  after 
gonorrhoea  is  produced  by  means  of  an  infection,  whether  purulent  or 
specific,  which  is  conveyed  to  the  cord  after  the  manner  in  Avhicli  the 
swelling  of  the  Joints  and  the  other  secondary  results  of  gonorrhoea 
are  produced:  and  I  think  we  need  not  hesitate  to  accept  this  con- 
clusion.'^ 

Thus  it  may  be  argued  that  of  Stanley's  cases  from  which  the  theory 
of  urinary  paraplegia  was  originally  constructed  there  is  not  one  which, 
according  to  our  present  knowledge,  is  to  be  explained  on  that  principle. 
It  is  to  be  presumed  that  in  every  one  there  was  disease  of  the  cord, 
either  as  a  primary  lesion  or  as  the  consequence  of  gonorrhoea,  to  which 
as  constantly  the  renal  changes  were  secondary.^ 

Many  other  instances  of  supposed  reflex  paraplegia  following  upon 
gonorrhoea,  some  of  which  have  ended  fatally  and  some  in  recovei-y,  are 
scattered  through  medical  literature,  but  in  the  absence  of  minule  ex- 
amination of  the  cord  it  may  at  least  be  said  that  none  are  conclusive. 
Dr.  Graves's  cases,  published  soon  after  Stanley's,  are  equally  equivocal 
Avith  his;  some,  indeed,  more  so,  if  that  is  ])ossible:^  in  one  a  tumor,  the 
size  of  "half  a  very  small  hazel-nut,"  Avas  found  external  to  the  sheath 
of  the  cord,  and  it  is  not  unreasonable  to  sup2)ose  that  this  may  liaA^e 


'  ' '  Cases  of  paraplegia  associated  with  gonorrhoea  and  stricture  of  the  ure- 
thra," by  W.  Gull,  M.D.,  Med.  Chir.  Trans.  1856,  vol.  xxxix.  p.  lO'). 

^  Med.  Chir.  Tran.s.  vol.  xxxix.  p.  199. 

^  See  case  quoted  by  Rayer,  loc.  cit.  a'oI.  iii.  p.  174,  also  by  Graves,  Clin.  Lec- 
tures, vol.  i.  p.  554. 

••  Graves,  Clin.  Lectures,  2d  edition,  vol.  i.  p.  563. 


218  UKINARY    PARAPLEGIA. 

had  some  share  in  producing  the  paralysis  which  existed  of  the  legs  and 
bladder, 

M,  Leroy  d'Etiolles  has  published  a  large  number  of  cases  of  supposed 
urinary  and  reflex  paraplegia,  many  of  which  were  of  gonorrhceal  origin, 
and  may  probably  be  explained  by  implication  of  the  cord  in  the  manner 
already  suggested.  Others  are  cases  in  which  the  Aveakness  of  the  legs, 
as  justly  remarked  b}'  Sir  \V.  Gull,  appears  to  be  not  more  definite  than 
as  part  of  general  debility,'  which  the  lower  extremities,  as  having  to 
support  the  weight  of  the  body,  usually  express  more  distinctly  than  the 
upper.  This  is  notably  suggested  in  the  instance  of  a  man  who  died 
with  an  abscess  in  the  neighborhood  of  the  bladder,  consequent  upon 
urethritis,  together  with  disseminated  renal  suppuration.  He  had  a 
trembling  gait,  and  dulness  of  sensation,  which  appeared  to  be  general. 
He  had  diarrhcea,  and  soon  sank  into  the  state  of  prostration  which 
characterizes  purulent  absorjition. 

Similar  remarks  will  apply  to  a  man  with  stricture  and  perineal 
abscess,  who  had  weakness  of  the  legs  with  some  obtuseness  of  sensa- 
tion, coincidently  with  a  febrile  attack  which  caused  much  pros- 
tration. 

Of  the  cases  related  by  this  author  those  in  which  the  reflex  theory  is 
best  borne  out  are  some  in  which  enlargement  of  the  prostate,  or  stric- 
ture of  the  urethra  independently  of  gonorrhoea,  were  followed  by  loss 
of  power  in  the  lower  limbs,  which  in  some  instances  was  restored  after 
the  discharge  of  an  abscess,  the  use  of  the  catheter,  or  some  other  surgi- 
cal procedure.  The  parajilegia  seems,  as  a  rule,  not  to  have  gone  beyond 
enfeeblement  of  the  limbs,  though  the  circumstiince  that  this  was  in 
some  cases  more  marked  in  one  leg  than  the  other  is  a  point  in  favor  of 
its  being  more  than  mere  weakness.  In  one  case  spasmodic  and  con- 
vulsive movements  (of  the  lower  extremities?)  occurred  at  the  time  of 
emission  of  urine.  In  this  instance  some  loss  of  sensation  was  noted  in 
the  lower  limbs,  while  the  motor  power  in  the  two  was  unequally 
impaired.  The  patient  recovered  after  the  evacuation  of  a  prostatic 
abscess. 

It  is  scarcely  to  be  doubted  that  in  this  and  in  a  few  similar  instances 
there  was  some  degree  of  real  paraplegia,  as  a  result  of  disease  of  the 
bladder  or  prostate,  and  therefore  properly  to  be  called  urinary;  but  to 
call  it  reflex,  or  in  other  words  to  assert  it  to  be  independent  of  disease 
of  the  cord,  is  to  go  not  only  beyond  evidence  but  beyond  probability. 
It  is  to  be  observed,  as  pointed  out  by  Sir  W.  Gull,-  that  where  para- 
plegia has  ensued  there  has  always  been  suppurative  inflammation, 
mostly  as  a  circumscribed  abscess  in  or  about  the  urinary  organs,  and 
the  inference  is  obvious  that  by  the  veins  or  otherwise  there  has  been 
some  extension  of  the  inflammatory  process  to  the  cord.  Myelitis  after 
gonorrhoea  is  a  sequence  which  may  be  considered  as  beyond  doubt;  and 
it  is  at  least  probable  that  a  similar  result  may  now  and  then  ensue  after 
other  kinds  of  suppurative  disease.  It  is  to  be  observed  that  with  many 
of  these  cases  there  have  been  rigors  or  other  febrile  symptoms  consistent 
with  purulent  absorption.  A  case  directly  to  the  point  is  quoted  by  Sir 
W.  Gull.'     A  man,  long  the  subject  of  stricture,  with  retention  of  urine, 

'  Case  of  Potemain,  pour  le  Docteur  R.  Leroy  d'EtiolIes,  TraiU  des  Para- 
plegics, p.  'i'i. 

*  Gmj's  Hospital  Reports,  vol.  vii.  p.  328. 

'  "  Cases  of  paraplegia  associated  with  gonorrhoea  and  stricture  of  the  ure- 
thra," Med.  Chir.  Trans.  1856,  vol.  xxxix.  p.  198. 


URINARY    PARAPLEGIA.  219 

underwent,  together  with  other  measures,  daily  dilatation  of  the  urethra; 
in  the  course  of  them  he  became  feverish  and  rather  suddenly  para- 
plegic. A  slough  formed  on  the  sacrum,  the  evacuations  passed  invol- 
untarily, and  he  died  one  month  after  the  outset  of  the  spinal  symjDtoms. 
*'A  small  quantity  of  pus  was  found  lying  on  the  outside  of  the  sheath 
of  the  cord,  opposite  the  bodies  of  the  sixth,  seventh,  eighth,  and  ninth 
dorsal  vertebrae,  and  one  of  the  vertebral  veins  in  the  lumbar  region  was 
full  of  well-formed  pus.  The  spinal  fluid  was  densely  coagulable.  The 
arachnoid  was  thickened,  and  presented  traces  of  recent  inflammatory 
exudation.  The  dorsal  portion  of  the  cord  was  very  distinctly  and  gener- 
ally softened.  An  old  stricture  existed  at  the  commencement  of  the 
membranous  portion  of  the  urethra,  and  several  false  passages,  one  open- 
ing into  an  abscess  behind  the  bladder,  and  two  returning  into  the  blad- 
der. The  vesical  veins  in  the  neighborhood  of  the  pelvic  abscess  were 
thickened  and  partially  obstructed  by  recent  lymph."  In  this  instance 
the  process  is  made  clear;  and  it  is  not  to  be  doubted  that  in  others  para- 
plegia has  similarly  been  brought  about  by  the  conveyance  by  the  veins 
of  purulent  or  septic  matter  from  the  urinary  to  the  spinal  region.  The 
veins  inside  the  spinal  canal  communicate  freely  with  those  outside  the 
vertebrae,  and  these  with  the  vessels  ascending  from  the  pelvis  and  lower 
extremities.  The  veins  of  the  vertebrae  have  no  valves,  so  it  is  conceiv- 
able that  blood  may  occasionally  flow  from  without  inwards,  even  though 
the  current  be  commonly  in  the  reverse  direction. 

Apart  from  the  cases  where  inflammatory  or  septic  products  may  be 
supposed  thus  to  have  impinged  upon  the  cord  we  find  nothing  to  en- 
courage a  belief  in  urinary  paraplegia.  It  does  not  arise  from  stone, 
great  as  is  the  nervous  irritation  shown  in  other  modes  which  stone,  es- 
pecially in  the  kidney,  produces. 

Other  observers,  mostly  coeval,  or  but  shortly  after  those  I  have  re- 
ferred to,  have  published  cases  which  at  the  time  were  explained  on  the 
reflex  theory,  but  which  now  present  themselves  with  sufficient  clearness 
in  another  light.  Mr.  Spencer  Wells  published  a  lecture'  on  "  Incom- 
plete Paralysis  of  the  Lower  Extremities  connected  with  Disease  of  the 
Urinary  Organs,"  but  the  condition  he  describes,  as  he  himself  would 
now  readily  admit,  is  one  in  which  the  bladder  has  simply  participated 
in  a  more  or  less  general  loss  of  nervous  power.  There  is  no  stricture 
or  definite  urinary  disease,  but  merely  a  loss  of  expulsive  power,  to- 
gether with  other  signs  of  muscular  failure.  The  description  applies, 
indeed,  with  much  accuracy  to  locomotor  ataxy.  This  transposition  of 
cause  and  effect  is  apparently  not  of  uncommon  occurrence  in  the  annals 
of  reflex  paralysis.  Loss  of  power  in  the  bladder  and  retention  without 
stricture  may  possibly  be  the  first  noticeable  signs  of  structural  disease 
of  the  cord;  cystitis  probably  will  quickly  follow,  and  it  may  not  be 
until  afterwards,  particularly  if  the  patient  be  in  bed,  that  the  paralysis 
becomes  evident  in  the  lower  extremities;  this  therefore  may  present 
itself  as  secondary  in  time,  and  ostensibly  in  cause,  to  the  urinary  dis- 
turbance. 

liecent  observation  has  added  nothing  to  the  records  of  reflex  para- 
plegia of  urinary  origin.  I  have  long  sought  but  hitherto  failed  to 
recognize  the  condition,  and  I  find  that  other  inquiries  have  met  with 
the  same  want  of  success." 

'  Med.  Times  and  Gazette,  November  14th,  1857. 
'  Dr.  Wilks,  Diseases  of  the  Nervous  System,  p.  231. 


220  URINARY    PARAPLEGIA. 

It  is  to  be  fairly  concluded  from  the  evidence  -which  has  been  brought 
forward  that — 

Paraplegia  may  as  a  rare  occurrence  ensue  upon  certain  inflammatory" 
disorders  of  the  bladder  and  neighboring  parts,  more  especially  when 
these  are  of  gonorrhcpal  origin;  it  is  then  a  result  of  the  extension  to  the 
cord  of  an  inflammatory  condition  by  infection  or  otherwise,  presents 
the  symptoms  of  myelitis,  and  may  be  fatal,  even  rapidly  so,  a  circum- 
stance inconsistent  with  tlie  supposed  character  of  reflex  paralysis. 

We  have  no  evidence  that  disease  of  the  kidney  extends  to  the  spine 
by  similar  means.  "When  the  suppurating  or  "^surgical"  kidney  con- 
curs with  paraplegia,  the  renal  condition  is  not  the  cause  but  the  conse- 
quence of  the  paralysis;  the  same  may  be  said  with  regard  to  renal  dilata- 
tion and  pyelitis. 

There  is  no  evidence  of,  but,  on  the  contrary,  many  reasons  to  doubt, 
the  existence  of  a  form  of  piaraplegia  dependent  on  the  state  of  the 
urinary  organs  but  independent  of  structural  change  in  the  spinal  cord. 
In  many  instances  supposed  to  be  of  this  nature  the  evidence  of  paraly- 
sis is  defective,  in  others  there  is  reason  to  believe  that  the  nervous  dis- 
order has  actually  preceded  the  urinary,  though  the  urinary  symptoms 
attracted  notice  as  the  first  sign  of  spinal  failure,  while  in  no  instance 
of  paraplegia  associated  with  urinary  disease  has  the  cord  been  asserted 
to  be  healthy  save  on  examination  which  has  been  entirely  insufficient 
and  inconclusive. 

Thus,  though  it  is  to  be  admitted  that  within  certain  limits  paraple- 
gia may  be  urinary,  there  is  no  e\'idence  to  show  that  in  any  circum- 
stances it  is  reflex. 


CHAPTER  XVII. 

DISEASES    OF   THE   URETERS   AND   LARGE   BLOOD- 
VESSELS. 

Diseases  of  the  Ureters. 

As  of  all  tubes,  diseases  of  the  ureter  tend  to  its  obstruction,  which 
whether  complete  and  of  both  sides  and  rapidly  fatal  by  suppression,  or 
iilcomjDlete  or  one-sided  so  as  to  give  rise  to  hydronephrosis,  is  of  so  great 
importance  as  a  source  of  disease  that  it  would  be  difficult  to  find  any 
other  part  of  the  body  where  so  small  an  extent  of  lesion  is  productive  of 
such  formidable  results.  The  ureters  have  little  liability  to  independent 
disease,  though  they  may  be  congenitally  defective  in  various  ways,  may 
be  involved  in  surgical  accidents,  and  are  apt  to  be  damaged  by  morbid 
products  and  share  in  morbid  processes  which  take  their  rise  elsewhere. 

An  ureter  appears  sometimes  to  have  been  impervious  from  birth  and 
shrunk  to  a  cord,  while  the  corresponding  kidney  has  become  atrophied, 
usually  with  cystiform  dilatation  of  the  jjelvis,  while  the  other  has  been 
hypertrophied. 

There  is  a  preparation  at  St.  George's  Hospital  showing  a  congenital 
obstruction  by  means  of  a  valvular  fold  of  mucous  membrane  in  the 
portion  of  the  duct  which  passes  through  the  wall  of  the  bladder.  The 
ureter  behind  this  was  dilated  to  the  thickness  of  the  colon  and  the  kid- 
ney in  a  state  of  cystic  degeneration. 

Sometimes  the  development  of  the  kidney  and  its  duct  appears  to 
have  been  arrested  simultaneously,  as  in  an  instance  under  my  own  ob- 
servation in  which  a  shrivelled  kidney,  weighing  but  43  grains,  was  con- 
nected with  a  ureter  which  though  partially  pervious  was  much  shrunk 
and  terminated  in  filaments  before  reaching  the  bladder.  In  this  in- 
stance, as  in  many  such,  there  were  no  symptoms,  but  the  importance  of 
the  condition  is  obvious  as  half-way  towards  suppression.' 

A  similar  result"  has  been  described  as  due  to  malposition,  the  duct 
starting,  not  at  the  bottom  of  the  infundibulum,  but  at  its  side,  so  as  to 
be  liable  to  obstruction  from  lateral  pressure;  but  I  must  refer  to  the 
chapter  on  Hydronephrosis  for  reason  to  believe  that  many  such  malpo- 
sitions and  valvular  arrangements  are  the  consequences  of  obstruction 
and  dilatation,  not  their  cause.  Supernumerary  renal  arteries  compress- 
ing the  upper  part  of  the  ureter  have  in  the  same  place  found  sufficient 
mention. 

The  ureters  are  little  exposed  to  violence  from  without  and  seldom 
suffer  except  by  such  injuries^  as  are  likely  to  produce  fatal  or  at  least 

'  St.  George's  Hospital  Museum.    Series  xi.  p.  7. 
»  Julius  Pollock,  Path.  Trans,  vol.  xvi.  p.  181. 
»  Path.  Trans,  vol.  x.  p.  209. 


222  DISEASES    OF    THE    URETERS    AND    LARGE    BLOOD-VESSELS. 

obvious  results.  Constrictions  of  the  ureter  have  been  attributed  to  this 
cause  sometimes  on  inconclusive  evidence.  An  instance  is  elsewhere  re- 
ferred to  where  stricture  of  the  ureter/  and  consequent  pyonephrosis 
were  traced  to  a  kick  from  a  horse.  After  rupture  of  the  kidney  by  ex- 
ternal violence  the  pelvis  has  been  known  to  become  tilled  with  coagu- 
lum,  and  the  ureter  thus  completely  and  permanently  stopped.  A  kick 
from  a  horse  on  the  right  hypochondrium  was  followed  by  collapse  and 
li£ematuria;  the  ha3maturia  did  not  occur  after  the  second  day,  and  the 
patient  recovered,  to  die  eighteen  months  later  with  granular  kidneys. 
It  was  then  found  that  the  kidney  had  been  ruptured  into  the  pelvis, - 
which,  together  with  the  ujiper  part  of  the  ureter,  had  become  filled 
with  coagulum,  to  the  complete  and  permanent  obstruction  of  the 
duct. 

Inflammation  of  the  ureter  is  usually  a  result  of  the  ascent  of  cystitis 
or  of  the  descent  of  stone.  In  the  former  relation  it  has  been  suf- 
ficiently referred  to  in  connection  with  pyelitis  as  the  result  of  gout  or 
gonorrhoea.  Under  inflammation  the  mucous  membrane  of  one  or  both 
ureters,  in  part  or  wholly,  may  become  swollen,  congested  to  a  purple 
color,  and  bathed  with  pus.  A  man  in  St.  George's  Hospital  had  con- 
tinued shooting  pains  in  the  lumbar  region,  pain  in  the  abdomen,  pus  in 
the  urine,  and  frequency  of  micturition,  which  symptoms  were  suc- 
ceeded by  uncontrollable  vomiting,  prostration,  and  death.  He  had 
been  sounded  for  stone  but  none  found,  nor  was  any  discoverable  after 
death.  Both  ureters  were  in  the  state  referred  to  from  near  the  bladder 
to  within  about  three  inches  of  each  kidney.  The  bladder  and  pelvis 
were  slightly  vascular  and  contained  small  quantities  of  pus.  No  other 
lesion  Avas  found  save  slight  recent  endocarditis.  The  kidneys  them- 
selves were  healthy.  There  was  no  history  of  gonorrhoea,  but  whether 
set  up  by  this  cause  or  by  calculi  which  had  escaped,  it  appeared  that 
the  inflammation  of  the  ureters  was  much  concerned  in  the  production 
of  the  symptoms.  °  The  ureter  has  been  known  to  become  lined  with 
lymph  under  the  inflammator}^  process,  or,  as  in  an  instance  recorded  by 
Murchison,*  to  be  coated,  in  common  with  the  calyx  of  its  kidney,  with 
a  loosely  adherent  membrane,  resembling  that  of  diphtheria,  shreds  of 
which  were  passed  wath  the  urine  during  life.  The  kidney  itself  was 
studded  with  small  abscesses.  In  this  instance  as  in  the  last  the  inflam- 
mation was  attributed  to  the  passage  of  stone,  but  none  found.  The 
ureter  has  been  known  to  become  surrounded  from  the  bladder  to  the 
kidney  with  suppurative  inflammation  of  the  cellular  tissue  which  in- 
volved also  the  renal  and  vesical  neighborhood;  in  the  case  I  refer  to  some 
small  calculi  were  found  in  the  peritoneal  cavity  and  the  affection  as- 
cribed to  perforation  by  them,  though  its  position  was  not  discover- 
able at  the  time  of  the  post-mortem  examination.  The  local  suppura- 
tion was  succeeded  by  pyaimia. 

Injury,  probably  ulceration,  caused  by  stone  may  be  succeeded  by 
stricture,  or  even  complete  occlusion,  and'  thus  give  rise  to  dilatation 
and  atrophy  of  the  kidney,  possibly  with  pyelitis  or  hydronephrosis  or 
taking  a  half  share  in  suppression  of  urine.  When  not  causing  com- 
plete obstruction  the  irritation  of  stone  at  the  top  of  the  ureter  will 

'  Pye  Smith,  Path.  Trans,  vol.  xxiii.  p.  159. 

'  St.  George's  Hospital  Museum.     Series  xi.  p.  4,  Path.  Trans,  vol.  xi.  p.  140. 

3  Path.  Trans,  vol.  xix.  p.  281. 

*  Ibid.  vol.  X.  p.  191. 


DISEASES    OF    THE    URETERS    AND    LARGE    BLOOD-VESSELS.  223 

sometimes  cause  this  i)art  of  it  to  become  thickened  aud  imbedded  in 
fat. 

It  is  not  necessary  to  add  to  what  has  found  phice  elsewhere  with  re- 
gard to  tubercular  disease  of  the  ureter:  thickening  and  ulceration  of  its 
wall  often  with  total  and  permanent  obstruction  of  the  channel  is  an  ac- 
companiment, usually  a  result  of  tubercular  disease  of  the  kidney. 
Malignant  growths  are  less  common,  as  proper  to  the  ureter,  than 
tubercular,  though  this  duct  is  oftin  encroached  uijon  by  cancer  from 
without.  Cancer  confined  to  the  ureter  is,  I  believe,  unknown,  though 
it  often  participates  in  renal  and  vesical  growths.  Its  walls  from  end 
to  end  '  have  become  thickly  infiltrated  with  malignant  matter  contin- 
uously with  a  like  formation  in  the  bladder,  and  superficial  patches  of 
fungous  growth  have  been  found  upon  its  mucous  surface  in  connection 
with  a  renal  growth  as  if  descending  germs  had  taken  root." 

The  Avair  of  the  ureter  has  been  known  to  become  infiltrated  in  con- 
nection with  the  development  of  lymphadenoma  elsewhere. 

Cancer  of  the  bladder  may  encroach  upon  and  stop  the  channel  of 
the  ureter  as  it  passes  through  the  vesical  wall,  and  the  same  result  may 
be  produced  by  polypoid  and  other  growths.  I  knew  a  case  in  which  a 
small  mucous  polypus  grew  from  the  bladder  in  such  a  position  as  ex- 
actly to  close  tlie  orifice  of  this  duct  and  cause  dilatation  of  it  and  of 
the  kidney.  Growths  external  to  the  urinary  organs  often  involve  the 
ureter;  some  such  have  been  referred  to  in  connection  witli  suppression 
of  urine;  tumors,  especially  when  malignant,  of  the  uterus,  vagina,  or 
ovary,  may  thus  invade  and  close  one  or  both  ureters;  an  instance  is  re- 
lated by  Dr.  Burdon  Sanderson^  of  a  fibro-cellular  tumor  which  had 
sprung  from  the  capsule  or  hilum  of  the  kidney  and  imbedded  the  ureter 
in  its  mass,  constricting  the  duct  at  its  origin  to  the  size  of  a  crow-quill. 
Beside  growths  of  various  kinds  the  ureter  has  been  compressed  by 
fibrous  bands,  the  result  of  inflammation  of  the  uterus  or  in  its  neigh- 
borhood, or  variously  constricted  in  consequence  of  displacement  of 
that  organ. 

It  is  not  necessary  to  remark  further  upon  dilatation  of  the  ureters, 
except  that  both  may  be  dilated,  together  with  the  pelves,  in  consequence 
of  chronic  difficulty  in  emptying  the  bladder,  and  that  with  such  stretch- 
ing the  valvular  passage  through  the  vesical  wall  necessarily  becomes  in- 
effective, so  that  the  contents  of  the  upper  chanels  become  contaminated 
by  those  of  the  lower,  with  results  which  are  explained  with  the  subject 
of  renal  suppuration.  In  connection  with,  and  probably  as  a  result 
of  the  dilatation  from  urethral  obstruction,  the  ureters  have  been 
known  to  become  prolajDsed  into  the  bladder  by  reason  apparently  of 
the  downward  pressure  exerted  by  the  swollen  and  rigid  cylinders 
into  Avhich  the  flaccid  and  yielding  tubes  have  became  converted.'' 

The  ureter  has  been  known  to  become  dilated  to  such  an  extent  as  to 
cause  an  abdominal  tumor  more  or  less  resembling  that  of  liydronephro- 
sis.  An  instance  is  mentioned  at  p.  101  in  connection  with  that  subject; 
another  was  reported  by  Mr.  Estlin"  and  is  referred  to  by  Dr.  Bright.    A 

'  Path.  Trans,  vol.  xviii.  p.  158,  case  by  Dr.  Bastian. 

^  Ibid.  vol.  i.  p.  155,  case  by  Mr.  Simon. 

'  Dr.  Coiipland,  Path.  Trans,  vol.  xxviii.  p.  126. 

*  Path.  Traits,  vol.  xiv.  p.  195. 

'  T.  Smith,  Patli.  Trans,  vol.  xiv.  p.  185. 

*  The  details  are  to  be  found  in  the  London  Medical  Gazette,  vol.  ii.  1828,  and 
■vol.  XX.  1837,  references  which  we  owe  to  Mr.  Morris. 


224  DISEASES    OF    THE    URETERS    AND    LARGE    BLOOD-VESSELS. 

man  had  a  tumor  *•'  of  an  oblong  form,  situated  in  the  right  hj'poclion- 
drium,  about  the  edge  of  the  rectus  muscle,  extending  nearly  from  the 
eleventh  rib  to  the  right  side  of  the  symphysis  pubes,  and  being  particu- 
larly prominent  about  the  situation  of  the  internal  abdominal  ring.  It 
soniewhat  distended  the  integuments,  so  as  to  be  perceptible  to  the 
eye,  and  might  be  considered  to  be  about  threa  inches  in  width." 
The  swelling  repeatedly  subsided  on  the  emptying  of  the  bladder  with 
a  catheter.  After  the  patient's  death,  which  occurred  under  an 
attack  of  influenza,  it  was  found  that  the  tumor  was  the  right  ureter 
enormously  dilated  and  thickened.  The  prostate  gland  was  the  seat  of 
three  semi-cartilaginous  tumors,  by  which  the  orifice  of  the  urethra  was 
obstructed.  The  bladder  was  sacculated  and  contained  a  large  number 
of  phosphatic  calculi  which  varied  in  size  from  that  of  a  chestnut  to  that 
of  a  pea.  It  is  not  explained  why  one  urethra  was  dilated  and  not  the 
other;  possibly  a  calculus  may  have  determined  the  inequality. 

The  ureter  may  be  perforated  by  abscesses  of  the  neighboring  parts 
and  the  pus  thus  find  exit  with  the  urine.  An  ordinary  psoas  abscess 
may  do  this,  as  is  testified  by  a  preparation  at  King's  College,  as  also 
may  a  pelvic  abscess  of  puerperal  origin.  A  patient  of  the  Late  Dr. 
Lee  in  St.  George's  Hospital  discharged  pus  with  the  urine  for  three 
years  after  pelvic  cellulitis  of  this  nature.  An  abscess  then  opened  upon 
the  back,  and  death  shortly  followed.  An  irregular  suppurating  cavity 
was  found  below  the  left  kidney,  which  opened  upon  the  loin  and  also 
into  the  ureter  which,  at  about  its  centre,  was  lost  in  the  abscess.  The 
kidney  was  dilated  and  atrophied.  This  case  bears  also  upon  the  sub- 
ject of  perinephritic  abscess  after  labor.  A  frecal  abscess  was  supposed 
by  Dr.  Ord  to  have  entered  the  ureter;  it  had  certainly  entered  some 
part  of  the  urinary  tract,  as  fffical  matter  was  found  in  the  urine;  but 
the  case  does  not  rest  on  post-mortem  evidence. ' 

Diseases  of  the  Rexal  Artery. 

The  renal  artery  is  liable  to  certain  anatomical  peculiarities  and  de- 
fects of  development  which  it  is  not  my  purpose  to  refer  to  except  so  far 
as  they  are  associated  with  renal  disease  or  deficiency.  The  supposed 
origin  of  hydronephrosis  in  compression  of  the  ureter  by  a  supernume- 
rary vessel  has  been  already  mentioned. 

In  many  cases  of  congenital  atrophy  of  one  kidney  the  artery  has 
been  found  to  be  incomplete  or  impervious,  notwithstanding  that  tlie 
duct  and  vein  have  been  open,  as  if  the  defect  in  the  artery  was  the 
cause  of  the  general  defect  of  development  or  nutrition.  The  shrivelled 
and  effete''  remnant  of  the  organ  has  generally  been  found  to  consist 
mainly  of  fibrous  tissue  and  even  in  some  cases  to  present  the  granuhir 
exterior  and  cystic  change  of  acquired  fibrosis;  not,  it  is  to  be  pre- 
sumed, that  there  has  been  any  morbid  formation  of  the  tissue  wiiich 
thus  appears  in  relative  excess,  but  rather  because  the  lack  of  nutrition 
has  told  Avith  greater  effect  upon  the  mere  vascular  and  mobile  struc- 
tures than  on  that  which  is  more  passive  and  enduring. 

It  has  frequently  been  noticed  that  where  one  kidney  has  been  thus 
destroyed  the  other  has  become  the  subject  of  inflammatory  disease,  due 
no  doubt  to  the  increased  work  thrown  upon  the  sole  organ. 

'  British  Med.  Journ.  September  7th,  1878,  p.  ;J48. 

'  See  cases  reported  in  the  Path.  Trans,  by  Mr.  Sydney  Jones,  vol.  viii.  p.  279: 
by  Dr.  Conway  Evans,  vol.  xvii.  p.  173;  by  Mr.  Pick,  vol.  xix.  p.  281. 


DISEASES    (>F    THE    URETERS    AND   LARGE    BLOOD-VESSELS.  225 

Embolism  and  thrombosis  have  been  considered  elsewhere.  An  in- 
teresting case  is  related  by  Dr.  Moxon,' in  which  a  short  embolic  clot 
from  a  diseased  heart  had  stopped  up  the  renal  artery  close  to  its  origin 
but  not  extended  into  the  organ;  tlie  aortic  end  of  the  plug  was  covered 
with  a  smooth  membrane,  and  we  are  led  to  infer  that  the  affected  artery 
was  completely  closed,  though  from  the  state  of  the  kidney  it  is  evident 
that  its  blood-supply  was  not  totally  cut  off.  Tlie  chief  interest  is  in 
the  contrasted  state  of  the  two  kidneys.  The  right,  which  remained  in 
free  connection  -with  the  circulation,  was  the  large  white  kidney  of 
Bright;  a  result,  probably,  of  the  disease  of  the  heart,  which  was  much 
dilated,  and  of  which  the  valves  were  thickened  as  the  result  of  rheu- 
matism. The  kidney  from  which  the  blood  had  been  cut  off'  was  prac- 
tically natural,  excepting  that  it  Avas  of  rather  small  size.  Dr.  Moxon 
observes  upon  the  infrequency  of  unilateral  Bright's  disease,  and  sug- 
gests with  probability  that  the  smaller  healthy  organ  had  been  saved  by 
the  accident  which  had  deprived  it  of  a  large  portion  of  its  blood. 

The  renal  artery  becomes  the  subject  of  atheroma,  though  perhaps 
scarcely  so  often  as  some  other  parts  of  the  arterial  system.  The  athe- 
roma has  been  such  that  the  vessel  has  been  nearly  but  not  quite  closed, 
with  the  result  of  fibrotic  atrophy  in  the  connected  organ,  which  was 
found  to  weigh  in  a  case  of  this  sort  recorded  by  Dr.  Greenfield  only  an 
ounce  and  a  half;  or  the  closure  has  been  made  complete  by  coagulum,. 
with  resultant  changes  of  a  more  acute  kind,  comprising  chiefly  anaemia 
of  tissue,  fatty  degeneration,  and  the  accumulation  of  leucocytes  in  and 
about  the  vessels.^ 

The  effect  of  complete  closure  of  tlie  renal  artery  is  to  stop  the  se- 
cretion of  urine,  with  comjjlete  suppression  should  both  kidneys  be  si- 
multaneously affected.  This  point  is  further  touched  upon  in  connection 
with  the  subject  of  suppression;  but  I  may  here  refer  to  a  case  in  which 
both  renal  arteries  were  so  compressed  by  an  aneurism  of  the  superior 
mesenteric  that  their  aortic  openings  were  reduced  to  mere  slits.  The 
patient  had  repeated  convulsions,  which  were  succeeded  by  coma  and 
death.  The  urine  was  incompletely  suppressed;  a  little  which  was  ob- 
tained with  a  catheter  was  highly  albuminous.^ 

Aneurism  of  the  renal  artery  occurs  both  from  embolism  and  as  the 
result  of  atheroma.  I  have  elsewhere  related  a  case  in  which  extra- 
vasation of  blood  about  the  kidney  external  to  the  pelvis  was  at- 
tributed to  the  bursting  of  an  aneurism  of  embolic  origin,  and  M.  01- 
livier*  has  given  an  instance,  which  probably  must  be  regarded  as 
exceptional,  in  Avhich  discharge  of  blood  with  the  urine  repeated  during 
the  course  of  six  years  was  found  to  be  associated  with  atheromatous 
aneurisms  of  the  renal  artery  and  its  branches.  An  aneurism  as  large 
as  a  filbert  was  found  at  the  bifurcation  of  the  renal  artery,  while  on  the 
further  branches  were  smaller  aneurismal  dilatations,  the  bursting  of 
which  into  the  dilated  pelvis  had  apparently  given  rise  to  the  re 
peated  haemorrhages.     Pyelitic  symptoms  not  unlike  those  of  stone  had 

'  Path.  Trans,  vol.  xix.  p.  267. 

"  "  Atheroma  of  the  Renal    Artery,    leading   to   Occlusion  of  the  Vessel   and 
Degenerative  Changes  in  the  Kidney."     Dr.  Greenfield,  Path.   Trans,  vol.  xxvi. 
p.  135. 

^  "  Aneurism  of  Superior  Mesenteric  Artery  compressing  both  Renal   Arte- 
ries.    Dr.  Burney  Yeo.  Path.  Trans,  vol.  xxviii.  p.  95. 

••  "  On  an  Undescribed  Varietj^  of  Pyelo-uephritis,"  by  Auguste  OUivier,  Arch, 
de  Physiologie,  1873,  vol.  v.  p.  43. 
15 


226  DISEASES    OK    THE   URETERS    AND    LARGE    BLOOD-VESSELS. 

been  produced  by  tbe  irritation  and  obstruction  caused  by  coagula  in 
the  pelvis. 

AVith  regard  to  disease  of  the  renal  vein,  it  is  not  needful  to  say 
more  than  has  already  found  mention  under  the  heading  of  Throm- 
bosis. 


CHAPTER    XVIII. 

EENAL    PARASITES. 

The  parasites  which  have  been  recognized  beyond  doubt  in  the 
human  kidney  are  but  four — the  Ecliinococcus,  ov  Hydatid,  the  Bilharzia 
hcematobia,  tlie  Strongulus  gigas,  and  the  Filaria  sanguinis  hominis. 
The  Pentastoma  deniicidatum  is  stated  to  have  been  seen  in  the  iiidney, 
and  the  Tetrastroma  renale  to  have  come  from  it.  Beside  these,  the 
Dadylus  aculeatas  and  the  Filaria  2jiscium,  under  the  title  of  Sjyiy'o^j- 
tera  hominis,  have  been  produced  as  urinary  parasites,  but  tliere  is  every 
reason  to  believe  that  their  appearance  in  this  relation  is  the  result  of 
accident  or  fraud.  The  filaria  will  be  considered  in  the  next  chapter  in 
relation  to  chyluria. 

Hydatids. 

The  only  parasitic  cyst  which  has  attracted  notice  in  the  kidney  is 
the  Ecliinococcus  or  Hydatid:  the  cysticercus  cellulosse  is  widely  scat- 
tered throughout  the  body,  and  it  is  scarcely  to  be  supposed  that  the 
kidney  enjoys  an  exemption  from  its  attacks,  but  I  cannot  find  that 
cysts  of  this  nature  have  been  recognized  in  this  situation. 

It  is  not  necessary  that  I  should  recapitulate  what  is  to  be  found  in 
every  text-book  with  regard  to  the  genesis  of  the  hydatid.  This  is  the 
cj'stic  stage  of  the  minute  taenia  echinococcus,  which  in  its  phase  as  an 
intestinal  worm  belongs  only  to  the  dog  and  the  wolf,  though  in  its 
cystic  or  hydatid  form  it  infests  many  animals,  of  which  the  human  be- 
ing is  one.  It  is  curious  that  this  tape-worm,  which  is  one  of  the  smallest 
of  its  race — it  consists  of  but  four  segments  and  is  altogether  only  of 
about  the  size  of  a  millet  seed — should  engender,  in  the  shape  of  the 
hydatid,  the  largest  parasitic  growth  to  which  the  human  body  affords 
residence.  The  eggs  of  the  taenia  pass  with  the  fseces  from  the  bowels 
of  the  animal,  and  are  conveyed  into  human  food  with  a  frequency  cor- 
responding with  the  intimacy  which  exists  belsween  man  and  '"the  faith- 
ful dog  which  bears  him  company." 

In  Iceland,  where  dogs  are  necessary  and  numerous — each  jieas- 
ant  has  on  an  average  six — and  where  men  and  animals  are  closely  associ- 
ated with  little  distinction  of  persons,  hydatids  are  said  to  be  fatal  to  one- 
seventh  of  the  population.  The  spread  of  the  disease  is  assisted  by  the 
strictly  homoeopathic  practice  of  the  Icelandic  quacks,  whose  favorite 
remedy  for  internal  administration  is  dog's  dung,  or,  as  it  used  to  be 
called,  Album  Grajcum.  It  is  easy  to  imagine,  also,  how  the  ova  of  the 
tjfinia  may  be  conveyed  by  water  into  which  dogs'  excrement  has  passed, 
or  may  cling  to  various  articles  of  diet  or  culinary  utensils  where  clean- 
liness is  unknown  and  dogs  ubiquitous. 

The  hydatid  disease  is  known  also  to  prevail  largely  in  Silesia,  where  it 
has  been  attributed  to  the  use  of  dog's  flesh  as  food:  tasnia,  or  their  eggs, 
probably  escape  from  the  bowel  in  some  of  the  butchering  processes,  and 


228  RENAL    PARAblTES. 

contaminate  the  edible  portions  of  the  animal.  By  such  means  some  of 
the  ova  of  the  taenia,  which  are  very  numerous — about  5,000  in  the  last 
or  only  fertile  Joint  of  the  minute  worm — are  carried  into  the  alimentary 
canal  of  the  animal  destined  to  lodge  the  hydatid,  and  thus  enter  ui)on 
a  new  phase  of  existence.  The  eggs  each  contain  a  minute  six-hooked 
embryo,  whose  occupation  appears  to  be  that  of  fixing  upon  and  boring 
through  the  structures  in  contact  with  which  it  finds  itself.  It  is  diffi- 
cult to  suppose  that  the  tissues  are  traversed  by  any  effort  or  design  on 
the  part  of  the  embryo;  more  probably  its  translation  is  accomplished  by 
some  such  process  as  that  by  which  needles  travel  from  one  part  of  the 
body  to  another.  The  movements  of  the  parts  of  the  body  on  each 
other  must  necessarily  tend  to  produce  the  frequent  displacement  of  the 
germ,  while  the  hooks  prevent  its  movement  save  in  one  direction. 
Should  a  vessel  be  penetrated  by  this  process,  the  embryo  is  of  coui.-e 
liable  to  be  swept  in  its  current,  and  implanted  in  one  of  the  capillanes 
to  which  it  leads.  Should  the  situation  reached  by  one  means  or  an- 
other be  suited  for  its  development,  the  hydatid  will  here  spring  from 
the  tape-worm  germ.  And  should  the  flesh  holding  the  hydatid  become 
the  food  of  a  dog,  its  germs  may  reproduce  the  ttenia  in  the  bowel  of  the 
animal,  and  thus  carry  on  the  eternal  interchange  between  intestinal 
worms  and  cystic  tumors. 

Thus  it  appears  that  two  animals  in  succession,  and  those  of  the 
nobler  species,  are  required  to  minister  to  the  engendering  of  a  tape- 
worm. It  is  a  little  puzzling  why  tsenia^  and  hydatids  should  not  flourish 
within  the  same  creature:  why  should  not  the  eggs  which  must  almn- 
dantly  escape  from  the  tteni^e  in  dogs'  bowels  start  on  their  travels'  there 
and  then,  and  develop  into  hydatids  within  the  same  animal  ?  They  do 
not  do  so.  On  the  contrary,  the  eggs  must  form  the  food  of  another 
individual,  usually  of  a  different  species,  so  that  the  tape-worm  is  proper 
to  certain  animals,  its  cystic  successor  to  other  and  different  animals. 
The  dynasty  is  continued  only  by  the  eating  of  the  flesh  which  contains 
the  cyst  by  the  animal  who  inherits  the  tape-worm.  Thus  the  worms 
commonly  belong  to  flesh-feeders,  the  cysts  possibly  to  animals  wliicli 
live  on  vegetables.  The  germ  which  belongs  to  the  hydatid  can  scarcely 
be  introduced  but  with  the  eating  of  flesh,  while  the  eggs  of  the  worm, 
being  detached  as  excrement,  may  cleave  to  anything.  It  is  to  be  ob- 
served that  at  each  transfer  the  egg,  or  the  cystic  germ,  as  it  may  be,  is 
exposed  to  the  process  of  digestion — usually  a  destructive,  but  in  the 
case  of  tliese  parasites  a  vivifying  process. 

The  proper  hydatid  cyst,  supposing  it  to  have  been  produced  within 
a  parenchymatous  organ,  is  surrounded  externally  by  a  concentric  layer 
of  tough  fibrous  tissue,  which  is  derived  from  the  organ  itself.  Within 
this  comes  the  parasitic  formation,  the  wall  of  which  has  been  divided 
into  two  portions,  described  as  the  ectocyst  and  the  endocyst.  The  outer 
portion,  or  ectocyst,  is  thick,  elastic,  and  laminated,  but  otherwise  homo- 
geneous. It  is  this  portion  of  the  cyst  which  is  so  readily  recognizable 
as  hydatid  membrane.  The  inner  layer,  or  endocyst,  is  excessively  tliin 
and  delicately  cellular;  it  appears  to  represent  the  germinal  membrane 
or  essentially  vital  part  of  the  animal,  and  to  supply  the  surface  by 
which  the  characteristic  fluid  is  secreted.  From  this  membrane  grow, 
and  push  inwardly,  what  have  been  described  as  daughter  cys/s  or  brood 
capsules,  as  part  of  which  scolices,^  or  rudimentary  tape-worm  heads,  after 
a  time  develop. 

'  (;«cJA?/;  =  a  worm. 


KENAL    PARASITES. 


229 


These  heads,  which  are  not  six-hooked  like  the  embryos,  but  armed, 
like  the  mature  worm,  with  a  com])lete  and  formidable  circle  of  hook- 
lets,  are  little  else  than  tape-worms  in  brief,  and  are  prepared  to  com- 
plete themselves  whenever  a  fitting  situation  presents  itself. 

For  this  opportunity  they  are  indebted  to  accident,  and  to  the  catho- 
lic appetite  of  the  dog.  The  vast  majority  must  perish  with  a  destiny 
unfulfilled,  but  those  that  find  fruition  and  completion  do  so  in  the 
duodenum  and  upper  small  boAvel  of  that  animal  of  whose  food  they 
have  made  part.  From  the  tape-worm  matured  in  this  situation  the 
circle  recommences.  The  scolices  or  booklets  which  have  been  de- 
rived from  them  are  continually  found  floating  loose  in  the  hydatid 
fluid,  where  their  presence,  easily  detected  with  the  microscope  in  small 
portions  withdrawn  with  the  hypodermic  syringe  or  aspirator,  furnishes 
ready  and  conclusive  evidence  of  the  nature  of  the  cyst.  But  it  is  to  be 
observed  that  these  creatures  are  not  naturally  thus  detached.  Dr. 
Cobbold,  whose  account  I  have  chiefly  followed,  points  out  that  their 
separation  from  the  brood-cysts,  however  frequent,  is  a  result  of  acci- 
dent, and  is  attended  with  the  death  of  the  animalcule  which  has  been 
thus  cast  loose. 

The  hydatid  fluid  is  aqueous,  and  slightly  saline,  in  its  uncomplicated 
state  quite  devoid  of  albumin.  The  saline  matter  is  chiefly  chloride  of 
sodium,  though  organic  salts  of  soda  have  been  found  in  it,  and  also 
crystals  of  cholesteriu  and  of  hasmatoidin.  In  renal  hydatids  have  been 
noticed  special  renal  products,  such  as  crystals  of  uric  acid,  of  oxalate 
of  lime,  and  the  phosphates.  The  absence  of  albumin  is  by  no  means 
invariable;  indeed,  after  each  tapping  of  a  hydatid  cyst  the  fluid  will  be- 
come more  and  more  serous  in  character,  until  at  last  it  is  highly  so. 
Finally,  it  may  suppurate  and  be  converted  into  an  encysted  abscess  full 
of  liquid  pus,  or  the  fluid  portions  may  be  gradually  absorbed,  to  leave 
a  shrunken  semi-calcareous  nodule,  in  which  the  shrivelled  remains  of 
the  secondary  cysts  are  flattened  and  folded  together,  imbedded  in  the 
earthy  residue. 

Hydatids  affect  different  organs  with  very  different  frequency.  Dr. 
Cobbold,  placing  together  his  own  researches  with  those  of  Davaine, 
gives  the  following  statement  of  the  number  of  times  they  have  been 
found  in  the  several  situations  they  frequent:' — 


Organs  affected. 

Cobbold. 

Davaine. 

Total. 

Liver 

161 
45 
22 
23 
22 
16 
13 
25 

165 
26 
40 
30 
20 
17 
12 
63 

326 

Abdomeu,  pelvic  cavity,  and  spleen 

Lungs 

71 
62 

Kidney  and  bladder 

Brain 

53 

42 

Bones 

33 

Heart  and  pulmonary  vessels 

Miscellaneous 

25 

88 

Grand  total 

'327 

373 

700 

The  liver  becomes  the  seat  of  the  parasite  far  more  often  than  any 
'  "  Lecture  on  Hydatid  Disease,"  by  Dr.  Cobbold,  Lancet,  1875,  p.  850. 


230  RENAL    PARASITES. 

other  organ;  about  as  often  as  all  the  rest  of  the  body  together.  This 
organ  is  affected  about  five  times  as  often  as  the  lungs  which  stand  next 
in  order  of  frequency,  about  six  times  as  often  as  the  kidney,  which  has 
the  next  place.  After  the  liver  there  is  no  marked  difference  between 
the  important  organs.  The  comparative  frequency  witli  which  the  liver 
is  attacked,  being,  as  it  is,  the  recipient  of  all  the  blood  which  returns 
from  tlie  alimentary  canal,  cannot  but  suggest  that  tbe  blood  is  largely 
concerned  in  the  distribution  of  the  ova.  Ova  have  indeed  been  detected 
in  the  blood  of  the  abdominal  veins,  after  the  experimental  feeding  of  an 
animal  with  tape-worm  joints.' 

If  one  of  the  ova,  on  its  way  from  the  bowel,  should  enter  a  vein,  the 
liver  will,  as  it  would  seem  almost  inevitably,  be  the  place  of  its  arrest; 
it  is  not  to  be  supposed  that  the  hooked  embryo  could  by  any  process 
short  of  boring  traverse  the  capillary  system  of  this,  or  indeed  of  any 
organ.  The  probably  constant  arrest  of  the  blood-borne  ova  in  the  liver, 
and  their  corresponding  exclusion  from  the  general  venous  blood,  ex- 
plains the  position  of  the  lung  with  regard  to  the  distribution  of  hydatid 
tumors.  The  lung  is  not  exempt  from  them,  but  shares  only  equally 
with  most  other  organs.  Did  these  germs  in  any  appreciable  proportion 
pass  through  the  liver,  and  thus  enter  the  systemic  venous  circulation, 
the  lung,  as  presenting  a  capillary  obstruction  which  must  be  traversed 
before  any  other  organ  is  reached,  would  probably  be  affected,  as  in  the 
case  of  pytemia,  incomparably  more  often  than  any  structure  which  re- 
ceives only  a  subsequent  and  fractional  supply.  But  this  is  not  the  case. 
We  may  therefore  infer,  in  the  first  place,  that  the  eggs  which  come  by 
the  portal  vein  stop  in  the  liver,  and  that  the  lungs,  kidneys,  brain,  and 
other  organs  all  receive,  by  some  mode  of  distribution  which  is  indepen- 
dent of  the  course  of  the  blood,  from  the  alimentary  canal:  whether  the 
germs  penetrate  the  aorta  and  are  thus  distributed  with  the  arterial 
blood,  or  whether  they  scatter  themselves  by  an  impartial  system  of  bur- 
rowing, remains  to  be  seen. 

The  liydatid  disease  affects  most  frequently  the  miudle  of  life,  though 
perhaps  no  part  of  its  course  can  be  asserted  to  be  absolutelv  exempt. 
Hydatids  have  been  found  in  tlie  kidneys  of  the  fu'tus,  but  they  appear 
to  be  almost  unknown  in  infancy.  They  attain  their  greatest  prevaknce 
between  thirty  and  fifty,  but  are  known  up  to  old  age.  The  cases  of 
hydatid  of  the  kidney  collected  by  Roberts — forty-seven  in  number — 
gave  a  mean  age  of  thirty-four;  the  youngest  sulgect  was  four,  tlie  oldest 
seventy-five.  This  statement  corresponds  with  and  evidently  includes 
results  obtained  Ijy  Beraud  from  forty-two  cases. 

Hydatids  in  general  appear  to  be  distributed  between  the  sexes  with 
much  impartiality,  though  in  Iceland  women  appear  to  bo  affected  more 
often  than  men,  probably  in  consequence  of  the  closer  confinement  of  the 
former  to  their  dwellings,  and  more  constant  use  of  the  water  which 
dogs  are  liable  to  have  fouled.  With  regard  to  the  kidney  in  particular, 
and  the  disease  as  we  know  it  in  less  extreme  latitudes,  men  suffer  more 
often  than  women  in  a  proportion,  as  Dr.  Roberts  reckons,  of  about  two 
to  one.  Of  sixty-three  cases  collected  by  this  author,  the  subjects  of 
forty-one  were  males,  of  twenty-two  females.  Of  Beraud's  cases,  forty- 
nine  in  number,  twenty-nine  related  to  males,  twenty  to  females. 

It  is  rare  for  both  kidneys  to  be  affected  with  hydatids:  the  left  is  so 

'  Experiments  by  Leuckart  upon  the  generation  of  the  Tcenia  serrata,  quoted 
by  Cobbokl,  p.  109. 


RENAL    PARASITES.  231 

ratlier  more  often  than  the  right.  Of  forty-two  cases  collected  by  Dr. 
Koberts,  both  kidneys  were  attacked  in  but  two;  of  the  rest,  the  left 
was  the  seat  of  the  disease  in  twenty-two  instances,  the  right  in 
eighteen. 

Hydatid  cysts  are  apt  to  be  imbedded  in  the  proper  glandular  sub- 
stance of  the  kidney,  either  in  the  cortex  or  the  cones,  and  to  present 
themselves,  or  possibly  to  originate,  in  the  cellular  spaces  under  the  cap- 
sule and  around  the  pelvis.  The  renal  tissue  undergoes  various  degrees 
of  atrophy  from  pressure,  the  remnant  often  presenting,  as  when  pres- 
sure is  due  to  any  other  cause,  a  positive  or  relative  excess  of  fibrous 
tissue. 

Hydatid  cysts  in  connection  with  this  organ  vary  in  size  from  an 
exceeding  minuteness  to  such  a  magnitude  as  to  hold  three  pints  or 
more. 

Many  cysts  of  different  sizes  often  exist  together:  in  Baillie's  case 
they  were  described  as  varying  in  size  from  an  orange  to  a  j)in's  head. 
"When  of  considerable  size  they  have  a  great  tendency  to  open  into  the 
pelvis,  which  leads  to  the  discharge  of  hydatids  with  the  urine,  which  is 
so  common  and  so  characteristic  of  this  disease.  The  orifice  by  which 
the  cyst  opens  upon  the  pelvis  may  be  comparatively  small:  in  a  case 
under  Rayer,  recorded  by  Beraud,  it  had  a  diameter  of  half  a  centi- 
metre.' 

It  is  stated  that  about  half  the  instances  of  renal  hydatids  have  at- 
tained such  a  size  as  to  be  appreciable  as  tumors  during  life;  at  least  one 
instance  has  been  known  in  which  the  tumor  was  regarded  as  ovarian,' 
and  an  operation  performed  in  this  view,  and  another  in  which  it  gave 
rise  to  a  suspicion  of  pregnancy.* 

From  the  last  case  it  would  appear  that  hydatid  growths  may  be 
large  enough  to  cross  the  median  line,  but  usually  they  do  not  go  beyond 
the  half  of  the  body  in  which  they  have  originated.  They  are  usually 
globular. 

A  growth  of  this  nature  in  the  kidney  is  commonly  painless  and  un- 
attended with  febrile  symptoms  or  any  constitutional  disturbance.  The 
prominent  signs  of  the  disease  apart  from  the  tumefaction  are  usually  to 
be  found  in  the  escape  of  the  hydatids  by  the  urethra,  or  possibly  by  the 
urethra  together  with  some  other  exit.  Hydatids,  or  pus'  from  a  sup- 
purating hydatid  cyst,  carrying  with  it  shreds  of  membrane,  have  been 
known  to  make  their  way  from  the  kidney  both  into  the  bladder  and 
into  the  bronchial  tubes,  so  that  the  contents  of  a  hydatid  cyst  of  renal 
origin  have  been  expectorated  and  passed  by  the  urethra  by  the  same 
person.  The  tendency  of  a  renal  abscess,  upon  whatever  it  may  depend, 
to  burrow  behind  the  diaphragm  and  into  the  root  of  the  lung,  is  one  of 

'  Beraud,  loc.  cit.  p.  22. 

*  Spiegelberg.  Quoted  in  Ziemssen's  Cyclopaedia,  vol.  xv.,  p,  7.")3.  An  opera- 
tion intended  as  ovariotomy  exposed  a  hydatid  cyst  of  the  kidney  of  the  size  of  a 
man's  head;  it  was  surrounded  by  firm  and  numerous  adhesions.  The  tumor  had 
been  developing  for  one  and  a  half  years  in  the  right  hypogastrium 

^Case  related  by  Dr.  Babington,  Med.  Times,  18.15,  p.  IGO 

■*  See  case  of  Mme.  B ,  which  occurred  in  the  practice  of  M.  Fiaux,  related 

by  Mr.  Beraud,  loc.  cit.  p.  63.  A  hydatid  cyst  of  the  riglit  kidney  presented  these 
two  openings  with  the  results  described.  The  case  ended  fatally,  and  post-mor- 
tem examination  was  performed.  An  instance  is  related  by  Rayer  (Inc.  cit.  vol. 
iii.  p.  'S'2'S)  in  wliich  the  pus  from  a  suppurating  hydatid  cyst  connected  with  the 
left  kidney  burrowed  behind  the  diaphragm  into  the  base  of  the  lung,  and  was 
thence  expectorated. 


232  RENAL    PARASITES. 

the  prominent  facts  in  renal  patliology.  Hj'datids,  presumably  renal, 
have  been  vomited — a  woman  who  had  a  tumor  in  the  side,  and' habitu- 
ally passed  these  cysts  by  the  uretlira,  vomited  a  large  quantity.'  It  has 
more  often  happened  that  the  urethral  exit  has  been  associated  with  one 
by  the  bowel;  several  instances  have  been  put  upon  record  in  which 
hydatids  have  simultaneously  made  their  way  out  by  both  these  chan- 
nels, but  either  they  have  not  terminated  fatally  or  no  post-mortem  has 
been  performed,  so  that  the  site  of  the  formation  must  remain  in  ques- 
tion. " 

It  is  to  be  observed  that  presumably  renal  hydatids,  becoming  as 
they  do  the  centres  of  suppuration,  travel  out  of  the  kidney  much  as  do 
calculi,  which  are  apt  to  burrow  their  way  out  by  the  agency  of  the 
same  penetrating  process. 

Points  of  ditference  are,  however,  to  be  observed  in  two  notable  re- 
spects. Suppuration  in  connection  with  a  stone  sometimes  breaks  into 
the  peritoneum  :  this  issue  has  not  been  recorded  in  regard  to  hydatids 
or  a  hydatid  abscess.  Matter  of  calculous  origin,  and  calculi  themselves, 
will  sometimes  make  their  way  out  through  the  back  ;  this  mode  of 
escape  has  never  been  verified  with  regard  to  renal  Jiydatids.  Several 
instances  have  been  recorded  in  which  hydatids  have  been  discharged  su- 
perficially from  the  lumbar  region,  but  proof  is  wanting  of  their  renal 
origin  ;'  in  one  instance  indeed,  in  which  a  post-mortem  was  made,  they 
were  found  to  have  come  from  outside  the  kidney. 

Roberts,  to  whose  research  in  this  subject  all  subsequent  writers  are 
likelv  to  stand  indebted,  thus  analyses,  with  regard  to  their  mode  of 
opening,  sixty-three  cases  in  which  hydatids  were  found  in  the  kidney 
or  passed  by  the  urethra. 

The  cyst  opened  into  the — 

Pelvis  of  the  kidney, in  47  cases. 

Pelvis  of  kidney  and  lungs, <.  1      «* 

Pelvis  of  kidney  and  intestines, "  3      " 

Pelvis  of  kidney  and  stomach, ««  j     «< 

Hydatids  discharged  by  urethra  in  52  cases. 

Lungs  alone, u  -^  << 

Did  not  open  at  all, "  8  " 

Opened  artificial!}', ,        •        .     "  2  " 

No  hydatids  discharged  by  urethra  in  11  cases. 

In  the  majority  of  cases  in  which  hydatids  are  formed  in  the  kidney 
it  appears  that  some  of  them  habitually  escape  with  the  urine  ;  the  ten- 
dency of  renal  hydatids  to  break  into  the  pelvis  is,  indeed,  the  charac- 
teristic by  which  the  affection  is  generally  recognized.  Of  presumably 
renal  hydatids  Roberts  estimates  this  result,  as  has  been  seen,  at  -47  of  63 

1  Schmidt,  Jahrh.  Bd.  87,  p.  205,  quoted  by  Roberts.  Also  quoted  by  Beraud, 
loc.  cit.  p.  70. 

5  A  case  is  related  by  ^I.  Rayer,  vol.  iii.  p.  552.  footnote,  in  which  a  man  who 
had  a  tumor  in  the  left  iliac  fossa  passed  hydatids  by  the  bowel,  pus  and  gas  by 
the  urethra.  The  same  author,  vol.  iii.  p.  554,  quotes  from  M.  Fourcroy  the  case 
of  a  perruquier  who  after  a  debaucli  passed  blood  and  hydatids  by  the  anus, 
hydatids  with  the  urine.     The  patient  recovered. 

The  case  of  a  woman  is  quoted  by  Davaine  {loc.  cit.  2d  edition,  p.  529)  in 
which  a  tumor  appeared  in  the  right  flank  after  an  effort,  and  subsequentlj' 
hydatids  and  pus  were  discharged  both  with  the  motions  and  urine.  The  patient 
recovered  after  nine  and  a  half  months'  illness. 

^  See  case  quoted  by  Rayer,  vol.  iii.  p.  578. 


RENAL    PARASITES.  233 

cases.  Beraiid  estimates  it  at  48  of  64.  But  it  is  to  be  borne  in  mind 
tliat  all  hydatids  that  thus  esca}3e  are  not  of  renal  origin.  They  may 
thus  make  their  way  out,  and  that  abundantly,  though  the  cyst  belong 
elsewhere.  In  a  case  under  Mr.  Birkett,  referred  to  at  page  :^34,  hyda- 
tids obtained  from  the  bladder  by  means  of  a  catheter  were  found  to  have 
proceeded  from  the  cellular  tissue  behind  it.  A  number  of  cases  in  which 
hydatids  were  passed  by  the  urethra  were  brought  together  in  the  "Med- 
ical Times," '  with  an  expression  of  belief  on  the  part  of  the  compiler 
that  in  most  the  parasites  were  derived,  not  from  the  kidney,  but  from 
the  cellular  tissue  in  some  part  of  the  abdominal  or  pelvic  cavity. 

But  however  often  hydatids  are  thus  connected  with  the  cellular  tis- 
sue, we  have  abundant  post-mortem  evidence  of  their  occurrence  within 
the  kidney  itself.  A  preparation  at  Guy's  Hospital  which  shows  a  hy- 
datid cyst  springing  from  the  'liilum  and  pressing  into  the  pelvis  illus- 
trates the  first  stage  of  the  process  ;  while  the  last  is  displayed  by  another 
at  St.  Bartholomew's,  which  consists  of  an  ovoid  mass  of  cretaceous 
matter,  scarcely  to  be  recognized  as  a  kidney,  but  being  all  that  was  left " 
of  this  organ  in  a  man  who  for  ten  years  had  jiassed  hydatids  by  the 
urethra. 

The  series  of  cases  to  which  I  have  referred  contains  a  curious  instance 
in  which  a  husband  and  wife  were  both  in  the  habit  of  passing  hydatids 
with  the  urine. 

This  mode  of  getting  rid  of  renal  hydatids  is  often  preceded  by  a  sen- 
sation of  something  having  broken  in  the  lumbar  region,  and  been  im- 
mediately attributed  to  a  blow  or  fall  or  jolting  movement.  The  attack 
resembles  the  ordinary  foi-m  of  renal  colic  which  attends  the  passage  of 
a  stone,  but  is  less  acute  than  the  latter  often  is.  The  pain  begins  usu- 
ally about  the  hip,  and  passes  down  the  line  of  the  ureter  into  the  thigh. 
The  testicle  is  often  retracted.  The  process  is  often  preceded  or  attended 
with  hsemorrhage.  These  attacks  are  often  attended  with  obvious  les- 
sening of  the  renal  swelling.  Mr.  Evans,  of  St.  Neots,^  described  a  case 
in  which  a  lobulated  tumor,  which  presented  througli  the  integuments 
the  dimensions  of  eight  inches  by  four,  totally  disappeared  after  successive 
discharges  of  hydatids  with  the  urine.  Many  hundred  cysts  of  this 
nature  were  voided  in  one  day. 

The  hydatid  outbreaks  are  often  separated  by  considerable  intervals 
— a  year  or  more — as  if  the  cavity  were  emptied  and  refilled  by  slow 
growth. 

Having  reached  the  bladder,  the  hydatid  may  cause  temporary  reten- 
tion of  urine,  and  give  occasion  for  the  use  of  a  catheter ;  or  they  may 
be  shot  out  of  the  urethra  with  considerable  force.  Women  have  been 
kuown  to  release  the  skins  from  the  orifice  with  the  fingers.  The  hyda- 
tid skins  do  not,  as  a  rule,  appear  to  have  a  very  irritating  effect  upon  the 
bladder,  though  occasionally  some  degree  of  cystitis,  with  a  discharge  of 
mucus  or  pus,  has  been  traced  to  their  influence.  More  often  the  urine 
contains  pus  which  is  of  renal  origin,  being  discharged  from  a  suppurat- 
ing cyst  in  process  of  natural  cure.  Hooklets  and  cretaceous  material 
have  been  found  in  the  pus  thus  produced.  Not  only  may  retention 
of  urine,  though  usually  in  this  case  of  a  passing  nature,  result  from  the 
transit  of  renal  hydatids,  but  fatal  retention  has  in  at  least  one  instance 

'  January,  1855,  p.  159.     See  also  Med.  Times,  1863,  vol.  ii.  p.  164. 
''Related  by  Dr.  Barker,  of  Bedford,  '•  On  Cystic  Entozoa  of  the  Human  Kid- 
ney,"' p.  11. 


234:  RENAL    PARASITES. 

been  produced  by  hydatids  not  of  renal  origin.  The  neck  of  the  bladder 
was  pressed  upon  by  a  growth  of  this  nature  belonging  to  the  celluhir 
tissue  between  the  bladder  and  the  rectum,  and  the  use  of  the  catheter 
delayed  until  it  was  too  late.' 

It  is  scarcely  necessary  to  say  that,  as  in  the  case  of  renal  tumors  in 
general,  the  urine  is  unaffected  so  long  as  there  is  no  discharge  of  ^^e 
contents  of  the  cyst  into  it. 

Calculi  sometimes  occur  in  the  same  kidney  with  hydatids,  apparently 
as  secondary  productions.  Crystals  -  of  triple  pliosphate,  oxalate  of  lime, 
and  uric  acid,  have  been  found  within  hydatid  cysts  passed  with  the 
urine,  and  it  is  easy  to  suppose  that  such  a  discharge  may  either  estab- 
lish phosphatic  dei^osition  as  a  consecpience  of  the  mucous  irritation 
which  it  involves,  or  may  simply  furnish  the  nuclei  on  which  any  urinary 
deposit  may  collect.  Chopart  *  found  in  tlie  pelvis  of  the  kidney  of  a 
child  four  years  old  hydatid  cysts,  or  what  were  thus  described,  some  of 
which  contained  a  stone  as  large  as  a  pea,  evidently  phosphatic,  in  their 
'interiors.  Stones  of  the  same  character  were  found  in  the  bladder.  In 
Blackburne's  instance  presently  referred  to,  in  which  there  was  but  one 
kidney,  and  that  the  seat  of  hydatids,  its  pelvis  contained  a  stone.*  And 
other  instances  of  a  similar  association  might  be  referred  to. 

Paraplegia  has  been  noted  concurrently  with  hydatids  of  the  kidney. 
Instances  have  been  recorded  in  which  the  leg  and  the  kidney  of  the 
same  side  have  been  affected.^  A  case  is  related  by  Dr.  Richardson  as 
having  come  under  the  notice  of  Mr.  Mackinder,  of  Gainsborough,"  in 
whicli  a  woman  who  had  paralysis  of  the  lower  extremities  and  bladder  was 
found  after  death  to  have  hydatids  in  the  liver  and  both  kidneys.  It  is 
not  to  be  supposed  that  there  is  any  but  an  accidental  connection  between 
the  renal  parasite  and  the  spinal  failure.  The  spine  may  be  diseased  in- 
dependently and  differently.  Or  it  is  possible  that  the  spinal  canal,  as 
it  proved  to  be  in  a  paraplegic  patient  not  long  ago  under  my  care  in 
St.  George's,  may  itself  be  the  seat  of  a  hydatid  formation.  Apart  from 
such  chances  it  is  unlikely  that  a  renal  hydatid  should  affect  the  spinal 
cord.  A  cyst  of  this  nature  cannot  encroach  by  filtration  like  a  malig- 
nant tumor ;  and  our  knowledge  of  renal  abscesses  sliows  it  to  be  highh'- 
im^jrobable  that  even  should  the  cyst  suppurate  the  matter  should  pene- 
trate tlie  s^Dine  or  in  any  wa}'  affect  the  cord. 

With  r(!gard  to  tiie  diagnosis  of  renal  hydatid,  this  condition  can 
scarcely  be  assured  but  by  tlie  passing  of  hydatids  or  booklets  with  the 
urine  while  a  tumor  of  renal  situation  is  recognized.  The  latter  Avill 
be  distinguished  by  the  rules  which  have  already  been  laid  down,  which 
should  suffice  todistinguisli  a  renal  from  an  ovarian  cyst  the  more  surely 
when,  as  in  case  of  hydatids,  the  formation  in  question  is  never  of  such 
large  size  as  to  obscure  its  relations.  In  case  of  otherwise  insoluble 
doubt,  the  aspirator  may  be  resorted  to.  The  character  of  the  fluid 
withdrawn  might  at  once  determine  between  the  two.     The  presence  or 

Related  by  Mr.  Birkett,  Med.  Times,  1855,  p.  161. 

^  Found  by  Mr.  Quekett  iu  case  reported  by  Dr.  Barker,  loe.  cit.  p.  10. 

^  Chopart,  Traite  dea  Maladies  des  Voies  Uriiiaires.  vol.  i.  p.  145.  Paris,  1830. 
It  is  not  improbable  tliat.  though  these  cysts  are  described  as  hydatids,  they  may 
have  been  cavities  of  some  other  nature.  At  the  date  of  this  ticcount  the  distinc- 
tion was  not  clearly  made 

^  See  footnote,  p.  'i'-Mi. 

^  Ziemssen's  Cyclopaedia,  vol.  xv.  p.  751,  quoted  from  Frerichs. 

*  Lancet,  1855,  vol.  ii.  p.  366. 


RExN'AL    PAKASITES.  235 

absence  of  albumin  must  not  be  solely  relied  upon:  hydatid  fluid, 
though  not  usually  albuminous,  may  be  highly  so,  and  conversely,  cysts 
other  than  hydatid  may  be  aqueous.  The  finding  of  booklets  or  lami- 
nated membrane  would,  of  course,  be  conclusive.  The  hydatid  fremi- 
tus is  seldom  if  ever  to  be  detected  in  connection  with  the  kidney;  it  is 
probable  that  the  tumor  is  seldom  superficial  enough  to  transmit  vibra- 
tions from  the  cyst  to  the  surface  with  the  necessary  distinctness. 

It  is  not  possible  to  state  the  duration  of  hydatid  of  the  kidney  more 
exactly  than  as  variable,  sometimes  very  brief,  sometimes  apparently 
unlimited.  The  cysts  are  apt  to  escape  by  the  urethra  in  successive 
crops,  separated  by  considerable  and  uncertain  intervals,  so  that  it  is 
difficult  to  say  that  any  one  is  the  last,  notwithstanding  that  even  years 
may  have  elapsed  since  its  occurrence.  One  of  the  longest  cases  of  the 
sort  on  record  is  one  quoted  by  Beraud'  from  M.  Vigla.  A  woman  37 
years  of  age  had  passed  hydatids  with  the  urine  every  year  of  her  life;  she 
had  had  an  attack  lasting  about  four  days  every  winter,  mostly  in  Janu- 
ary, with  now  and  then  others  at  odd  times.  A  woman  mentioned  by 
Davaine,*  whose  left  kidney  after  death  was  found  to  have  been  trans- 
formed into  a  bag  of  hydatids,  had  been  liable  for  twenty  years  to  at- 
tacks of  renal  colic  with  escape  of  the  cysts  by  the  urethra.  The  case 
quoted  from  Blackburne^  by  the  same  author,  in  which  the  disease  at- 
tacked a  solitary  kidney,  proved  fatal  in  four  years.  Many  instances  of 
a  different  kind  have  been  placed  on  record  in  which  the  patient  has 
apparently  recovered  after  a  few  outbreaks  or  even  one.  A  natural  cure 
is  sometimes  brought  about  by  the  process  of  suppuration.  This  finally 
arrests  the  cystic  growth  by  killing  the  parasite,  and  leaves  an  abscess 
which  may  at  last  cure  itself  by  discharge. 

Hydatid  of  the  kidney,  as  already  stated,  is  less  fatal  than  when  sin- 
gle organs  or  organs  which  have  no  such  ready  exit  as  the  ureter  affords 
are  the  seat  of  the  disease.  Of  the  cases  recorded,  only  a  minority  have 
terminated  fatally;  and  of  those  some  have  done  so  from  causes  uncon- 
nected with  the  growth  which,  in  several,  bas  presented  itself  as  a  post- 
mortem surprise.  Relying,  as  we  must  do  in  dealing  with  a  disease  of 
the  infrequency  of  this,  more  upon  published  records  than  personal 
experience,  it  follows  that  the  jiroportion  of  fatal  cases  should  appear 
larger  than  it  is.  Those  which  present  this  ending  are  more  noticeable 
than  many  Avhich  do  not;  some  instances  are  brought  to  light  only  by 
post-mortem  examination,  so  that  it  is  inevitable  that  cases  whicli  are  com- 
pleted by  death  must  show  a  larger  proportion  in  literature  than  in  nature. 
But  even  in  literature  it  is  not  very  great.  Of  sixty-three  cases  collected 
by  Roberts,  recovery  was  assumed  to  have  taken  place  in  twenty. 
Twenty  terminated  fatally,  but  in  nine  of  tbese  death  was  brought  about 
otherwise  than  by  the  hydatid  disease,  so  that  this  affection  caused  tbe 
death  of  but  eleven  of  the  number 

The  tendency  of  renal  hydatids,  as  has  been  shown,  is  to  break  into 
the  pelvis  and  wear  themselves  out  by  discharge,  while  the  functions 
are  sufficiently  carried  on  by  the  kidney  which  does  not  participate  in 
the  disease.  But  if  this  be  incapacitated  by  any  simultaneous  or  preced- 
ing accident,  or  if,  as  in  Blackburne's  case,  the  affected  kidney  be  soli- 
tary, fatal  results  may  be  brought  about  by  partial  or  complete  suppres- 

'  Beraud,  loc.  cit.  p.  57. 
^  Davaine,  loc.  cit.  p.  551. 
3  Ibid.  p.  551. 


236  RENAL    PARASITES. 

sion  of  urine,  and  in  the  rare  instances  where  hoth  kidneys  have  been 
involved  in  the  hydatid  disease,  the  same  issue  may  present  itself. 
Fatal  results  have  followed  the  opening  of  the  cyst'  into  the  bronchial 
tubes,  and  have  also  been  known  to  occur  from  extensive  pleural  etfu- 
sion,-  set  u])  by  the  progress  of  the  growth  in  the  same  direction.  Death 
has  been  known  to  have  been  brought  about  by  the  exhaustion  of  a  ])ur- 
ulent  discliarge  with  the  urine,  derived  from  a  defunct  hydatid  cyst, 
and  also  to  have  ensued,  as  more  often  happens  in  the  case  of  the  liver, 
from  the  formation  of  a  closed  abscess  in  the  place  of  one. 

In  a  case  under  M.  Nelaton,  related  by  Beraud,^'  a  fatal  conclusion 
followed  the  artificial  opening  of  a  renal  hydatid  cyst:  the  cyst,  which 
lay  in  close  relation  to  the  bowels,  and  had  contracted  extensive  perito- 
neal adhesions,  was  punctured  by  means  of  caustic.  It  is  difficult  to 
say  in  this  case  how  far  the  result  was  due  to  the  disease  and  how  far  to 
the  remedy.  In  other  instances  death  has  followed  upon  senile  gan- 
grene, phthisis,  or  some  accident  not  obviously  connected  with  the  para- 
sitic affection. 

The  usually  favorable  delivery  of  renal  hydatids  makes  it  unjustifiable 
to  encounter  risk  in  search  of  artificial  cure,  save  in  the  presence  of  cir- 
cumstances which  add  exceptional  danger  to  the  condition.  What  can 
be  done  beneficially  may  be  briefly  stated.  Vermicides,  administered 
by  the  stomach,  appear  to  be  powerless  as  regards  parasites  in  the  tis- 
sues. This  is  made  evident  in  the  case  of  the  liver,  an  organ  which  is 
more  advantageously  situated  than  any  other  to  receive  the  influence 
of  drugs  introduced  into  the  stomach  aiid  admitted  into  the  system  prob- 
ably by  the  portal  vein.  Hepatic  hydatids  flourish  in  contempt  of  all 
such  modes  of  attack;  and  there  is  no  reason  to  suppose  that  such  growths 
elsewhere  will  yield  to  them,  exposed  as  they  are  only  in  a  remote  de- 
gree. 

I  have  satisfied  myself  that  the  oil  of  male  fern  is  useless  in  this  re- 
lation; and  though  many  iiistances  have  been  reported  in  which  dis- 
charge of  hydatids  with  the  urine  have  ceased  after  the  use  of  turpen- 
tine, there  is  no  reason  to  believe  that  they  would  not  equally  have  come 
to  an  end,  transitoi'y  as  their  nature  is,  had  this  drug  not  been  given.' 

The  question  of  surgical  treatment  can  arise  only  in  those  few  cases 
where  a  tumor  presents  itself  near  the  surface.  And  even  with  such, 
if  no  danger  obviously  threatens,  if  there  be  no  embarrassment  of  renal 
function,  no  rapidity  of  increase,  and  no  sign  of  tlioracic  complication, 
we  may  generally  be  content  to  wait  upon  nature.  If  there  is  reason  to 
interfere,  it  would  probably  be  best  to  use  the  method  so  often  and  so 
successfully  used  witli  regard  to  the  liver:  puncture  the  cyst,  where  it 
is  least  covered,  with  a  very  fine  aspirator,  and  with  it  draw  off  much, 
but  not  necessarily  all  of  the  fluid  contained.  This  will  at  least  be  a 
measure  of  relief,  and  with  repetition  it  may  be  curative;  for  the  con- 
tents of  the  cyst,  at  first  aqueous,  will  become  more  serous  with  each 
renewal  until  at  last  they  are  so  much  so  as  to  constitute  an  element  in 
which  the  parasite  cannot  live;  the  solid  structures  belonging  to  which 
will  gradually  shrink,  concrete,  and  become  inert.  This  method  causes 
less  pain  and  constitutional  disturbance  than  that  which  has  been  of  late 

'  Davaine,  loc.  cit.  p.  467. 

'  Davaine,  loc.  cit.  p.  550,     Quoted  from  Livois. 
^  Beraud,  Des  Hydatides  den  Reins,  p.  80. 

••  See  case  of  apparent  recovery  after  the  use  of  turpentine  under  Mr.  Curling, 
Med.  Times,  1863,  vol.  ii,  p.  164. 


KENAL    PARASITES.  237 

employed  under  the  name  of  electro-puncture,  and  is  probably  safer 
than  it.  I  have  tried  both  with  hepatic  hydatids,  and  have  no  hesitation 
in  preferring  the  former. 

A  single  puncture,  and  that  without  the  removal  of  fluid,  or  with  the 
removal  of  but  a  trifling  quantity,  has  been  known  to  be  followed  by 
rapid  diminution  of  the  tumor.  The  larger  methods,  which  seek  the 
extraction  of  the  cysts,  in  propria  persona,  by  trocar,  caustic,  or  inci- 
sion, are  scarcely  likely  to  suggest  themselves  with  regard  to  cavities 
seated  as  deeply  as  in  the  kidney. 

Apart  from  the  evacuation  of  hyatids  from  without,  the  fact  that 
their  escape  into  the  pelvis  and  so  out  has  been  determined  by  blows  and 
falls  must  be  recognized;  but  such  natural  surgery — surgerv  not  of  the 
surgeon — would  be  too  uncertain  in  result  to  be  recommended  even  were 
it  possible,  which  it  perhaps  never  is,  to  diagnose  as  renal  a  non-dis- 
charging hyatid. 

Measures  of  palliation  are  thus  on  every  ground  more  likely  to  be 
called  for  than  such  as  aim  at  cure.  The  vesicles  have  been  helped 
along  the  ureter  by  external  pressure  directed  by  the  patient  himself, 
and  their  removal  from  the  bladder  has  often  been  assisted  with  the 
catheter.  This  instrument  will  of  course  be  at  once  resorted  to  should 
there  be  any  distress  from  retention  of  urine.  The  use  of  diuretics  has 
been  thought  to  facilitate  the  discharge  of  the  cysts;  Beraud  '  found  in 
one  case  that  these  escaped  after  nitre  or  white  wine;  but  probably  such 
remedies  will  bring  away  only  cysts  which  would  as  surely  escape  with- 
out them.  During  the  attack,  should  it  be  attended  with  much  pain, 
such  treatment — opium,  warm  baths,  etc. — may  be  indicated  as  would 
be  proper  were  a  calculus  in  transit. 

BiLHARziA  H^matobia;  Distoma  H^matobium;  Distoma  Capejstse. 

Endemic  Hematuria. 

It  has  long  been  known  that  several  parts  of  the  old  world,  most  no- 
toriously the  island  of  Mauritius,  but  also  certain  districts  belonging  to 
the  continent  of  Africa,  including  Egypt,  especially  the  valley  of  the 
Nile,  and  also  the  southern  extremity  of  the  same  quarter  of  the  globe, 
comprising  the  Cape  of  Good  Hope  and  Port  Natal,  are  tlie  seats  of  an 
endemic  disorder  of  which  h^ematuria  is  a  prominent  symptom.  The 
ha^maturia  of  Mauritius  has  been  longest  under  notice,  and  its  symp- 
toms have  been  minutely  and  repeatedly  described,  so  as  to  leave  no 
doubt  that  the  disease  is  of  the  same  nature  as  that  which  prevails  on 
the  continent;  yet  is  has  been  imperfectly  traced  pathologically,  and 
though  it  is  said  that  the  Bilharzia'-  lias  been  found  in  the  island,  yet  it 
must  be  allowed  that  the  nature  of  the  insular  endemic  is  rather  a  mat- 
ter of  inference  than  demonstration. 

The  corresponding  affections  of  Egypt  and  the  Cape  have  been  more 
completely  worked  out,  owing  to  the  labors  chiefly  of  Bilharz  at  Cairo 
aad  of  Dr.  John  Harley  in  regard  to  the  southern  localization,  and  followed 
in  both  these  widely-removed  fields  to  identically  the  same  cause,  the 
ravages  of  a  minute  bloodworm,  Avith  which  the  name  of  its  discoverer 
has  been  connected.     It  is  hardly  to  be  supposed  that  the  intermediate 

'  Loc.  cit.  p.  93. 

*  Sonsino,  Lancet,  May  27th,  1882,  p.  553. 


238  RENAL    PARASITES. 

portions  of  Africa  are  entirely  destitute  of  the  parasite  which  infests  its 
extremities;  and  indeed  it  is  believed  that  the  animal  frequents  the 
whole  of  the  eastern  seaboard  of  this  continent,  manifesting  a  preference 
for  littoral  rather  than  the  inland  districts,  and  for  low  rather  than  high 
levels.  Further  research  must  add  to  our  knowledge  of  the  distribution 
of  the  disorder;  but  we  know  enough  already  to  make  it  impossible  to 
consider  the  liEematuria  of  Africa  excepting  in  relation  to  the  parasite; 
and  as  to  the  haematuria  of  the  Mauritius,  it  is  so  similar  in  symptoms 
to  that  of  Africa  that  it  can  scarcely  be  of  a  totally  different  nature. 
The  consideration  of  the  Bilharzia,  therefore,  is  inseparable  from  that  of 
endemic  hajmaturia,  and  it  may  be  convenient  to  sketch  in  slight  outline 
the  natural  history  of  the  parasite  before  referring  in  particular  to  the 
symptoms  which  it  has  been  ascertained  to  produce,  or  which  are  pre- 
sumably associated  with  a  similar  cause.  Our  knowledge  of  the  animal 
in  its  Egyptian  location  has  been  largely  contributed  to  by  post-mortem 
research,  and  is  fairly  complete  so  far  as  relates  to  the  portion  of  its  ex- 
istence during  which  it  is  a  denizen  of  the  human  body;  as  yet  we  know 
it  at  the  Cape  chiefly  by  ova  which  have  been  passed  with  the  urine  dur- 
ing life;  it  is  i)ossible  that  our  knowledge  in  this  respect  may  soon  be 
extended. 

The  animal  whose  existence  was  discovered  by  Bilharz  in  the  year 
1851,  and  since  described  by  Kuchenmeister  and  Leuckhart,  is  a  distinct 
species  of  fluke  or  trematode.'  The  creature  enjoys  complete  sexual  dis- 
tinction: the  male,  which  has  much  the  contour  of  a  leech,  is  about  half 
an  inch  in  length,  the  female  measures  about  four-fifths  of  an  inch,  but 
is  of  such  slender  proportions  that  much  of  its  body  is  imbedded  within 
that  of  the  male  during  the  act  of  sexual  association.  The  body  of  the 
male  contains  a  canal  which  has  been  called  gynecophoric,  within  which 
nujjtial  chamber  the  female  is  for  the  time  inclosed.  The  comparatively 
plum^)  body  of  the  male  is  somewhat  tuberculated,  that  of  the  female  is 
smooth.  With  both  sexes  there  are  oral  and  ventral  suckers,  by  means 
of  which  the  animal  secures  its  position.  The  eggs  are  oval  or  pear- 
shaped.  They  have  a  spine  or  sharp  jjoint,  usually  at  the  hinder  ex- 
tremity, but  sometimes  at  the  side.  Dr.  John  Harley  found  in  his 
South  African  cases  the  hinder  spine  only;  in  Egypt  both  kinds  have 
been  found.  According  to  Dr.  Zincarol,-'  of  Alexandria,  the  ova  from 
the  bladder  have  a  terminal  spine,  those  from  the  intestine  a  lateral  one. 
The  eggs  give  exit  to  ciliated  embryos,  which  move  about  with  much 
activity,  as  Griesiuger  witnessed  in  the  bowel,  and  as  has  been  often 
seen  in  the  urine. 

Though  the  eggs  may  possibly  be  thus  hatched  in  the  urine,  the  em- 
bryo cannot  live  long  in  this  fluid;  water  is  the  place  of  its  further 
development.  For  its  prolonged  existence  pure  or  only  brackish  water 
is  required.  Urine  is  fatal  to  it,  though  not  at  once.  Harley  never 
found  a  live  embryo  in  this  fluid.  Eoberts  was  more  fortunate,  and  wit- 
nessed the  activity  of  the  embryo  in  this  secretion  several  hours  after  it 
had  been  emitted;  but  we  have  the  evidence  of  Cobbold  as  to  the  impos- 
sibility of  jDreserving  its  life  for  forty-eight  or  even  for  twenty-four 
hours,  excepting  in  water  which  is  free  from  organic  admixture.  Traces 
of  blood,  mucus,  or  decomposing  matter  of  any  kind  added  to  spring 
water  caused  the  death  of  the  embryo  within  twenty-four  hours,  as  also 

'  Cobbold,  loc.  cit.  p.  197. 
*Path,  Trans,  vol.  xxxiii.  p.  410. 


KENAL   PARASITES.  239 

did  a  mere  tinting  with  permanganate  of  potash  or  carmine.  So  small 
a  proi^ortion  of  urine  as  a  drachm  to  a  quart  was  fatal  to  the  embryo  in 
forty-eight  hours. 

Thus  it  api^ears  tliat  for  the  continuance  of  the  race  the  egg  or 
embryo  must  be  passed  with  the  urine  into  fresh  or  brackish  water;  if 
the  egg,  it  is  hatched,  as  Cobbold  has  shown,  almost  immediately  upon 
coming  into  contact  with  the  water;  and  it  then  commences  the  extra- 
human  portion  of  its  existence,  of  which  nothing  is  ascertained  excej^t 
that  a  time  comes  when  the  creature,  in  some  shape  as  yet  unknown,  re- 
fcuriisfrom  the  water  to  the  vertebrate  body. 

The  2)arasite  infests  man  and  the  monkey.  A  variety,  which  is 
stated  to  be  distinct,  has  been  found  in  the  ox  and  sheep.  In  the  portal 
vein  of  a  monkey  which  had  been  imported  from  Africa  and  died  in  the 
Zoological  Gardens,  Dr.  Cobbold  found  so  fine  a  specimen  of  this  fluke 
that  he  was  for  a  time  disposed  to  distinguish  it  as  the  Bilharzia  magna. 

The  animal  in  its  adult  state  belongs  especially  to  the  blood;  it  is 
found  particularly  in  the  vessels  of  the  bladder,  and  in  the  abdominal 
veins,  the  portal  vein  and  its  intestinal,  mesenteric,  and  splenic  tribu- 
taries, and  the  hepatic  vein. 

Ova  have  been  abundantly  found  in  the  liver,  to  which  it  is  evident 
that  they  may  readily  be  conveyed;  and  egg-shells  within  the  left  ven- 
tricle, the  means  of  their  reaching  which  are  less  obvious.  Though  the 
worms  are,  as  a  rule,  confined  to  the  blood,  the  eggs  are  somewhat  widely 
distributed.  Tliey  are  deposited  mainly  in  the  mucous  membranes  of 
the  bowel  and  of  the  urinary  system,  in  which  they  give  exit  to  the 
ciliated  and  active  embryos  which  escape  with  the  evacuations  to  find 
adventures  as  yet  unknown  to  us,  but  no  douljt  to  provide  adequately  for 
the  continuance  of  the  race.  The  worm  in  the  blood  appears  to  cause 
less  disturbance  than  would  be  expected;  the  presence  of  the  parasite  is 
chiefly  made  known  to  us  by  the  irritation  occasioned  by  its  progeny  in 
certain  mucous  membranes.  In  the  large  intestine,  which  is  the  jjart  of 
the  bowels  chiefly  affected,  the  ova  were  found  in  polypoid  excrescences, 
and  their  presence  indicated  by  diarrhoea,  with  discharge  of  mucus  and 
blood,  and  much  jiain  of  the  nature  of  colic.  In  the  urinary  membrane, 
which  is  the  chosen  site  for  the  dej)osition  of  the  eggs,  the  results  are 
produced  by  which  the  disorder  is  especially  characterized.  The  blad- 
der is  found  to  be  extensively  spotted  with  ecchymosis,  and  variously 
pigmented;  the  mucous  membrane  is  sometimes  partially  detached  or 
undermined  by  accumulations  of  eggs  beneath  it,  and  it  is  sometimes 
lifted  up  into  warty  or  villous  elevations.  These  changes  are  necessarily 
attended  with  much  irritation  and  the  discharge  of  blood  and  mucus, 
together  with  eggs,  embryos,  egg-shells,  and  now  and  then  a  deceased 
parent. 

The  accumulated  and  partially  imbedded  ova  often  become  the  cen- 
tres of  oxalic  and  lithic  deposits  from  the  urine,  so  that  vesical  calculi 
are  common  complications  of  the  parasitic  disease.  Similar  changes 
occur  in  the  lining  of  the  ureters,  and,  less  often,  of  the  })elves.  The 
ureters  are  apt  to  become  obstructed  or  constricted,  and  the  kidneys  to 
present  in  consequence  the  various  phases  of  dilatation  and  atrophy 
which  follow  ujion  urethral  stricture.  They  may  become  the  subjects  of 
hydronephrosis,  or  tliere  may  be  pyelitis  even  to  the  degree,  as  in  a  case 
described  by  Griesinger,  of  converting  the  organ  into  a  mere  bag  of  pus. 
But  beside  these  consecutive  changes  it  appears  that  the  kidneys  are 
affected  by  the  parasitic  disorder  in  ways  which  arise  within  themselves. 


2-iO  RENAL    PARASITES. 

It  is  sufficiently  clear  that  the  pelvis  of  the  kidney  affords  lodgment  to 
the  ova,  as  do  other  parts  of  the  uriiiary  membrane,  though  not  with  the 
same  frequency,  and  adult  animals  have  been  found  in  the  renal  blood- 
vessels. Whichever  may  be  the  effective  sources  of  irritation,  the  kid- 
neys are  described  as  swollen  and  congested,  affected  with  a  dark  red 
hyperemia,  and,  in  tlie  later  stages,  fatty.  Whether  these  changes 
depend  upon  venous  obstruction  or  upon  irritation  of  the  renal  sub- 
stance by  parasitic  intrusion  are  questions  which  must  be  answered  by 
further  observation. 

Both  in  Egypt  and  also  in  a  person  Avho  had  come  from  Natal,  filariaj' 
have  been  found  in  individuals  who  have  also  given  residence  to  the  Bil- 
harzia;  but  the  animals  and  the  symptoms  produced  by  them  are  totally 
distinct  and  the  concurrence  accidental. 

AVe  know  the  symptoms  of  the  disorder  as  it  occurs  in  Egypt,  chiefly 
from  the  researches  of  Bilharz  and  Griesinger,  as  in  South  Africa  chiefly 
from  those  of  Dr.  John  Harley,  though  as  regards  both  localizations 
many  other  observers  have  more  recently  added  to  our  stock  of  knowl- 
edge. *'  Gravel  and  ulcers  of  the  kidneys,"  if  we  may  trust  the  state- 
ment of  Prosper  Alpinus,^  appear  to  have  been  frequent  among  the 
Eg\'ptians  even  as  far  back  as  the  year  1645 — not  to  mention  a  still  older 
reference  to  the  turning  of  water  into  blood,  Avhich  may  have  found  its 
suggestion  in  the  diseases  proper  to  the  place.  So  common  is  the  para- 
site in  Egypt  that  M.  Griesinger  found  it  in  117  of  303  autopsies.  Its 
effects  are  most  noticeable  from  June  to  August,  and  least  so  from  Sep- 
tember to  January.  The  prevalence  of  the  disease  in  summer  is  owing, 
as  Dr.  Cobbold  supposes,  to  the  prevalence  of  the  larvae,  wheucesoever 
derived.  The  symptoms  of  the  disease  are,  in  the  first  place  at  least, 
chiefly  local,  vesical,  and  prostatic  irritation,  with  the  passing  of  blood, 
mucus,  sometimes  pus,  and  not  seldom  calculi,  which  may  be  either  of 
vesical  or  renal  origin.  Pain  in  the  back  is  mentioned,  though  the 
bladder-symptoms  appear  to  be  usually  more  prominent  than  the  renal. 
A  form  of  dysentery,  diarrhoea  with  the  passing  of  blood  and  mucus,  is 
a  frequent  concomitant.  "With  the  local  symptoms  there  is  often  much 
loss  of  flesh,  anaemia,  and  nervous  prostration.  ''Egyptian  chlorosis '' 
has  been  spoken  of  as  one  of  the  results  of  the  disease,  but  it  appears 
that  this  especial  affection  is  rather  to  be  attributed  to  another  parasite, 
the  Ancldistoma  duodenaJe.^  Beside  dysentery,  pneumonia  has  been 
mentioned  among  its  fatal  results,  though  it  would  seem  from  our  ex- 
perience in  South  Africa  that  the  disorder  seldom  leads  to  a  fatal  issue. 
It  is  stated  that  in  Egypt  it  occasionally  presents  itself  in  an  acute  con- 
stitutional form,  resembling  typhus  in  its  symptoms  and  duration.  The 
symptoms  appear,  however,  to  be  iisually,  and  as  far  as  we  know  in 
South  Africa  always,  of  the  chronic  and  local  sort,  with  hematuria  and 
vesical  or  i^rostatic  irritation,  without  much  or  with  no  early  effect  upon 
the  general  health. 

A  little  blood  is  passed,  mostJy  after  the  urine;  there  is  little  fre- 
quency of  micturition,  though  perhaps  a  difliculty  in  retaining  the  water 
when  the  call  has  come.  In  one  instance  the  prostate  appeared  to  be 
solely  affected,  since  there  were  no  properly  vesical  or  renal  symptoms. 
Mucous  casts  were  passed,  imbedding  the  eggs,  while  small  quantities  of 

'  Zincarol,  Med.  Times,  January  21st,  1882,  p.  76.     Cobbold,  Lancet,  January 
14th,  1882,  p.  84.     Sonsino,  Med.  Times,  May  2Tth,  1882,  p.  5.56. 
^  Quoted  by  Davaine,  2d  edition,  p.  320. 
^  Sonsino,  Lancet,  3Iay  2Ttli,  1882,  p.  553. 


KENAL    PARASITES.  241 

Tenons  blood,  mixed  with  nrine,  were  from  time  to  time  passed  b}'  ihe 
urethra,  the  rest  of  the  secretion  being  nnaffected,  save  that  it  was  clondy 
with  mncns."  Such  symptoms  appear  to  be  seldom  attended  with  danger 
to  life;  the  only  fatal  case  referred  to  by  Dr.  Harley  is  that  of  a  Scotch- 
man, who  died  ''worn  out  by  the  various  concomitants  of  the  disorder '' 
at  the  age  of  seventy-six.  Among  concomitants  must  be  mentioned  the 
]iassage  of  renal  calculi,  in  two  instances  of  which  Dr.  Harley  found  the 
irgs  of  the  parasite  in  the  interior  of  the  stone;  constituting,  as  we  can 
•arcely  doubt,  the  point  of  primary  deposit.  This  observation  is  of 
interest  as  placing  beyond  doubt  the  particijjation  of  the  kidneys  in  the 
disease. 

The  calculi  appear  to  be  chiefly  composed  of  oxalate  of  lime, 
though  uric  acid,  which  is  a  frequent  deposit  in  such  cases,  takes  part. 

The  urine  itself  was  not,  in  Dr.  Harley's  cases,  usually  changed  in 
quantity,  or  specific  gravity,  or  in  quality,  save  by  the  addition  of  the 
jiarasitic  pi'oducts,  with  blood,  and  its  proper  amount  of  albumin.  It 
was  not  ammoniacal  nor  alkaline,  but,  on  the  contrary,  apt  to  deposit 
uric  acid.  None  of  the  ordinary  products  of  cystitis  Avere  usually  pres- 
ent, though  sometimes  there  was  a  little  blood-stained  stringy  mucus. 
In  a  case  presumably  of  prostatic  location  the  blood  was  passed  only 
after  breakfast  or  defsecation. 

The  disorder  in  South  Africa  appears  to  attack  foreigners  and  colo- 
nists in  preference  to  the  native  population.  KaflEirs  are  exempt,  while 
coolies  suffer.  The  disease  seems  to  be  nearly,  but  not  absolutely,  limited 
to  males.  When  females  suffer,  it  is  said  often  to  disappear  with  the 
advent  of  the  menses,  almost  always  to  cease  on  the  occurrence  of  preg- 
nancy.^ It  was  not  transmitted  to  a  wife  whose  husband  had  passed 
numbers  of  eggs  every  day  of  married  life.  Three  or  four  healthy  chil- 
dren had  been  born  to  the  pair.  Boys  after  the  age  of  three  or  four  are 
most  liable,  the  complaint  often  disappearing  about  puberty.  It  has, 
however,  been  known  to  have  been  acquired  at  the  age  of  fifty,  and  to 
have  proved  fatal  at  seventy-six. 

The  endemic  hasmaturia  of  the  Isle  of  France  has  long  been  known, 
but  has  not  yet  been  definitely  traced  to  the  Bilharzia  ;  there  can,  how- 
ever, be  little  doubt  that  it  is  produced  by  this  or  some  closely 
similar  parasite.  The  symptoms  and  incidence  of  the  disease  are  almost 
exactly  those  described  at  the  Cape.  Repeated  attacks  of  hsematuria 
occur  with  frequency  of  micturition  and  other  signs  of  vesical  irritation. 
The  blood  is  in  but  small  amount,  not  so  much  as  to  discolor  the  whole 
bulk  of  the  urine,  but  only  its  last  portion,  after  the  discharge  of  which 
a  few  drops  of  blood  may  escape  unmixed.  Small  clots  are  occasionally 
seen.  Under  the  microscope  have  been  found  oxalate  of  lime,  blood, 
mucus,  and  pus,  with  scales  of  blood-epithelium.  Probably  before  long 
this  list  will  include  the  parasite.  =* 

The  disorder  is  here,  as  elsewhere,  often  associated  with  attacks  of 
renal  colic.  It  is  said  that  three-fourths  of  the  children  in  the  island 
suffer  from  it,  both  sexes  being  affected,  but  boys  apparently  with  the 
more  frequency,  since  of  these  it  is  said  that  few  escape.  The  disorder, 
as  elsewhere,  often  disappears  about  the  time  of  puberty.  It  has  been 
attributed  to  masturbation  and  the  use  of  spiced  dishes — causes  which, 

'  Dr.  John  Harley,  Med.-Chir.  Trans,  vol.  liv.  p.  48. 
•^  Dr.  Allen,  Lancet,  July  15tli,  1883. 

'  Todd,  Clinical  Lectures  on  Diseases  of  the  Urinary  Organs, 
16 


242  KENAL    PARASITES. 

were  thej  effective  in  this  respect,  might  be  expected  to  give  rise  to  the 
disease  in  many  other  places — and  with  some  probability  to  the  quality 
of  the  water  drunk.  A  form  of  hfematuria,  presumably  of  the  same  ori- 
gin, has  been  stated  to  occur  in  Madagascar.' 

It  is  of  importance  to  inquire  Avith  regard  to  the  creature  a  portion 
only  of  whose  existence  is  passed  within  the  liuman  body,  whence  it  may 
be  derived  and  how  admitted.  As  it  is  not  known  save  as  a  human  para- 
site, its  derivation  must  be  a  matter  of  conjecture,  but  water  is  to  be 
suspected  as  the  means  of  its  distribution.  The  Nile  is  thought  to  be 
the  vehicle  of  the  parasite  in  Egypt,  and  it  has  been  suggested  that  some 
of  the  fish  of  that  teeming  river  may  furnish  its  temporary  abode.  Dr. 
Cobbold  thinks  it  more  likely  that  the  larval  form  infests  some  gastero- 
pod  mollusc  local  to  the  district  where  the  disorder  occurs.  At  Uiten- 
hage  and  Port  Elizabeth,  at  the  other  extremity  of  the  continent,  the 
disorder  is  likewise  attributed  to  water  which  is  supplied  by  exposed 
streamlets  in  which  water-plants  abound.  It  is  stated  that  in  South 
Africa  those  only  are  liable  ^  who  drink  river  water  or  the  water  from 
marshes  or  pools,  those  who  use  well  or  rain  water  being  exempt.  Dr. 
Harley  has  shown  reason  to  suspect  watercresses  as  conveying  the  para- 
site, Avhether  themselves  affording  attachment  to  it,  or,  as  he  suggests, 
by  means  of  minute  mollusca  in  which  the  parasite  is  lodged  adhering  to 
the  plant.  It  has  been  suggested  that  the  ova  find  admission  into  the 
body  during  bathing,  and  that  the  frequency  with  which  boys  are  af- 
fected as  compared  with  girls  is  due  to  their  more  often  doing  so.  The 
urethra  has  been  regarded  as  the  point  of  entrance,  and  it  has  been  stated 
that  in  South  Africa  the  natives  are  in  the  habit  of  tying  grass  round 
the  orifice  before  wading  or  swimming  across  a  river.  On  the  other 
hand,  it  has  been  remarked  that  in  South  Africa  the  Kaffirs,  who  bathe 
often,  are  exempt  from  the  disease,  while  the  coolies,  who  bathe  seldom, 
are  often  affected.  Whether  the  parasite  is  admitted  by  the  urethra  or 
by  the  mouth  must  be  regarded  as  at  present  uncertain  ;  what  we  know 
of  the  habits  of  other  similar  creatures  and  the  abundance  with  which 
these  are  found  in  the  jiortal  vein,  "where  indeed  they  were  first  detected, 
would  lead  us  to  attach  the  greatest  probability  to  entrance  by  the  mouth; 
entrance  by  the  urethra  is  supported  by  the  concentration  of  the  disorder 
upon  the  urinary  organs  and  the  blood-vessels  in  immediate  connection 
with  them.  It  has  been  suggested  that  the  ova  may  be  deposited  in  the 
skin  and  thus  enter  the  superficial  veins  ;  but  if  thus  introduced  they 
should  be  conveyed  to  the  systemic,  not  the  portal  vessels.  Dr.  Harley 
tells  us  that  persons  bathing  in  the  Booker  river,  about  which  the  dis- 
ease is  common,  are  sometimes  attacked  in  consequence  with  an  nrticari- 
ous  eruption,  and  that  the  colonists  of  Natal  are  constantly  affected, 
when  first  resident,  with  indolent  sores,  especially  upon  the  legs,  which 
resemble  syphilitic  ulcers.^  It  is  stated,  however,  by  Dr.  Guillemard, 
that  the  ''Natal  sores  "  are  distinctly  and  solely  caused  by  the  bite  and 
subcutaneous  burrowing  of  a  species  of  tick  which  is  quite  unconnected 
with  the  Bilharzia  ;  and  though  bathing  must  be  admitted  as  Avith  pos- 
sibility affording  means  for  the  introduction  of  the  animal,  the  evidence 
is  against  cutaneous  entrance. 

The  Bilharzia  appear  sometimes  to  die  out  like  a  dynasty,  so  that  the 

'  On  the  Endemic  Hcematuria  of  Hot  Climates,  by  Dr.  Guillemard,  p.  36. 
'  Dr.  J.  Harley,  Med.-Chir.  Trans,  vol.  liv.  p.  60. 

^  The  ova  of  the  Bilharzia,  which  were  found,  as  supposed,  in  Delhi  boils,  have 
been  shown  to  be  altered  hair-bulbs. 


RENAL    PARASITES.  243 

disease  comes  to  an  end  spontaneously  ;  this  occurs  especially  about  the 
time  of  puberty.     As  to  treatment,  since  the  habitation  of  the  parent 
worms  is  in  the  blood,  they  are  practically  out  of  the  reach  of  vermi- 
cides ;  this  organized  fluid  could  not  be  supposed  to  tolerate  any  admix- 
ture which  would  be  destructive  to  animal  organisms  within  it.     All  we 
can  do,  therefore,  when  the  disease  is  established  is  to  support  the  patient 
against  it  and  use  such  local  measures  as  may  be  effective  against  its  more 
accessible  manifestations.     The  latter  endeavor  resolves  itself  into  the 
destruction  by  some  suitable  injection  of  as  much  of  the  parasite  or  its 
progeny  as  is  lodged  in  the  coats  of  the  bladder.     Whatever  may  be  ef- 
fected with  regard  to  the  unhatched  eggs,  it  would  not  appear  tliat  any 
trouble  is  needed  to  destroy  the  ciliated  embryo,  since  urine  itself  is  fatal 
to  it.    With  regard  to  the  worms,  most  of  them  are  obviously  out  of  reach; 
those  only  which  have  penetrated  the  vesical  wall  are  thus  assailable ; 
and  even  here  not  too  readily,  for  the  guest  is  protected  by  the  sensi- 
bility of  the  host.     The  more  active  disinfectants  or  parasiticides  could 
scarcely  fail  to  injure  the  bladder.     Experimenting  Avith  non-irritant 
solutio7is  Dr.  Harley  got  the  best  results  from  iodide  of  potassium  in  a 
strength  of  five  grains  to  the  ounce.     This  gave  rise  to  no  vesical  irrita- 
tion and  was  followed  by  the  expulsion  of  various  parasitic  products.  Dr. 
Harley  made  trial  of  other  remedies,  including  oil  of  male  fern,  worm- 
wood, and  quassia,  with  less  satisfactory  results.     It  is  obvious  that  there 
is  room  for  further  experiment :  quinine,  the  sulphides,  and  permanga- 
nate of  potash  might  be  suggested.     Dr.  Allen,  of  Pietermaritzburg, 
emi^loyed  a  concentrated  solution  of  santonine  in  absolute  alcohol,  and 
injected  this  in  quantities  of  two  drachms  into  the  empty  bladder,  with 
the  constant  result  of  cystitis,  as  might  have  been  anticipated,  but  with 
the  effect,  as  he  thought,  of  destroying  the  parasite.     It  is  indeed  possi- 
ble that  the  ova,  like  the  bladder  itself,  may  have  been  seriously  injured 
by  this  application  and  the  disorder  locally  suspended  ;  but  such  relief 
is  scarcely  worth  the  cost  if  the  parasite  remain  intact  in  the  deeper 
veins.     Dr.  Allen '  supposed  also  that  by  the  administration  of  santonine 
by  the  mouth  the  creature  would  be  killed  in  the  blood-vessels,  a  pre- 
sumption from  which  local  treatment  might  be  inferred  to  be  unneces- 
sary.    The  destruction  of  the  worm  in  the  blood-vessels  by  medicine 
conveyed  by  the  blood  cannot  as  yet  be  regarded  as  proven  or  as  possible. 
Dr.  Cobbold  disapjoroves  of  injection,  and  directs  his  attempts  to  the  ar- 
rest of  the  hemorrhage  rather  than  to  the  destruction  of  the  parasite. 
He  thinks  the  catheter  should  be  avoided  as  injurious,  and  parasiticides 
as  useless.     Nothing,  in  his  view,  should  be  done  to  disturb  the  plugs 
which  spontaneously  form  at  the  points  of  ulceration.     He  has  found 
good  results  from  the  administration  by  the  mouth  of  buchu  and  bear- 
berry. 

With  regard  to  prevention,  if  the  parasite  is,  as  there  is  reason  to  be- 
lieve, brought  by  water  and  admitted  by  the  mouth,  it  is  obvious  that 
spring  or  rain  water  should  be  drunk  when  possible,  to  the  exclusion  of 
that  from  streams  and  pools.  But  with  the  latter,  infection  should  be 
completely  intercepted  by  boiling  or  effectual  filtration.  Fish  and  vege- 
tables from  suspected  water  shoiuld  be  wholly  avoided,  or  at  least  never 
used  as  food  until  after  having  been  raised  in  cooking  to  boiling  point. 
In  view  of  modes  of  entrance  other  than  by  the  alimentary  canal,  there 
should  be  no  bathing  but  in  the  sea. 

1  Lancet,  July  15th,  1882  ;  also  April  14th,  1883. 


244 


RENAL    PARASITES. 


The  Stroxgulus  Gigas. 

The  "worm  which  has  been  thus  called,  or  otherwise  the  Eustrongyhis 
giqas,  both  names  alike  bearing  witness  to  its  rotundity  and  to  its  size, 
is  not  only  the  largest  individual  parasite  which  takes  residence  within 
the  human  body,  but  is  the  largest  nematode  known.  It  may  nearly  be 
compared  in  its  dimensions  to  one  of  the  snakes  common  in  this  country, 
the  male  to  the  adder,  the  female  to  the  common  field  snake,  AVith  the 
thickness  of  about  half  an  inch  the  male  attains  the  length  of  about  a 
foot,  the  female  of  about  three  feet.     The  serpentine  proportions  of  the 


Strongnlus  piRas  in  the  CoDepre  of  Surgeons,  "found  in  the  kidney  of  a  patient  of  the  late 
Thomas  Sheldon,  Esq."  The  woodcut  is  of  one-half  the  actual  dimensions.  The  animal,  a  female, 
18  inches  long,  has  been  laid  open  to  show  the  intestinal  canal,  spiral  CESophagus.  and  reproductive 
organs. 

creature  are  testified  to  by  the  older  writers,  who,  when  they  found  these 
parasites  in  the  kidneys  of  wolves  and  dogs,  described  them  as  serpents 
in  this  situation. 

This  variety  of  strongnlus,  though  not  peculiar  to  the  kidney,  is  most 
often  found  in  this  organ,  of  which  it  becomes  the  denizen  in  a  large 
number  of  animals.     It  is  said  to  occur  with  especial  frequency  in  the 


BENAL    PARASITES.  245 

weasel  and  the  North  American  mink,  destroying  the  snbstance  of  the 
kidney  and  giving  rise  to  calcareous  dejiosit  in  its  walls.  Among  the 
animals  in  which  this  worm  has  been  found  Cobbold  mentions  the  dog, 
wolf,  puma,  glutton,  racoon,  coati,  otter,  seal,  ox,  and  horse. 

The  general  aj^pearance  and  something  of  the  anatomy  of  the  animal 
may  be  gathered  from  the  accompanying  woodcut,  which  represents  the 
specimen  which,  on  Cobbold's  authority,  we  may  accept  as  undoubtedly 
from  the  human  body,  which  is  preserved  at  the  College  of  Surgeons. 
The  adult  worm,  to  follow  Cobbold's  description,  is  cylindrical,  more  or 
less  red  in  color,  and  somewhat  thicker  behind  than  in  front.  The  head 
is  broadly  obtuse,  the  mouth  being  supplied  with  six  small  wart-like  pa- 
pillae, whereas  the  lumbricus,  which  the  strongulus  someAvhat  resembles, 
has  but  three.  Two  of  the  papillre  correspond  with  the  commencement 
of  the  two  lateral  lines  of  the  body.  There  are  six  other  longitudinal 
lines  Avhicli  traverse  the  body  from  end  to  end.  The  tail  of  the  male 
shows  a  simple  cup-shaped  bursa,  which  jiartly  conceals  the  simple  spi- 
culum.  The  tail  of  the  female  is  blunt  and  pierced  by  the  centrally 
placed  anal  opening.  The  vulva  is  situated  near  the  head  in  the  ventral 
line.  The  eggs  are  stout  and  oval,  measuring  -j^o-"  in  length  and  -^^-a" 
in  breadth. 

In  the  stages  of  existence  through  which  this  parasite  passes  before 
entering  the  human  or  mammalian  body  and  assuming  the  form  to  which 
the  term  gif/fts  is  applicable,  it  appears  that  certain  fish,  as  probably  in 
the  case  of  the  Bilharzia,  play  the  part  of  intermediary  bearers.  It  has 
been  inferred  by  Hchneider,  and  the  interference  accepted  by  Leuckart 
and  Cobbold,  that  the  worm  known  as  the  FUaria  cystica,  which  is  found 
encysted  beneath  the  peritoneal  membrane  of  the  Galaxias  scriba  and 
Si/ndranchus  laticandatus,  is  the  sexually  miniature  and  undeveloped 
strongulus.  It  is  easy  to  imagine  that  the  minute  inhabitant  of  the  fish 
may  be  transferred  to  the  fish-eating  animal,  the  otter,  seal,  and  even  the 
dog  and  the  wolf,  and  man  himself,  but  it  is  less  easy  to  explain  its 
transmission  to  the  ox  and  the  horse.     Probably  water  is  the  vehicle. 

With  regard  to  the  geographical  distribution  of  the  strongulus,  it  ap- 
pears to  be  less  uncommon  in  the  Low  Countries  than  elsewhere  both 
in  man  and  animals.  Of  the  eight  cases  i-eferred  to  as  probable,  two 
were  recorded  in  Holland.  Of  another,  the  subject  was  a  Frenchman 
who  had  been  to  Walcheren.  Two  others  occurred  in  France.  Of  the 
eighth,  from  which  was  obtained  the  specimen  in  the  College  of  Surgeons 
(see  woodcut),  nothing  further  is  known  than  that  it  was  taken  from  the 
kidney  of  a  patient  of  the  late  Thomas  Sheldon,  Esq. 

The  chosen  position  of  this  worm  is  the  pelvis  of  the  kidney,  in  which 
it  lies  in  a  coil  or  knot;  but  as  it  has  been  passed  with  the  urine  in  the 
human  subject,  it  is  obviously  not  limited  to  any  subdivision  of  the 
urinary  cavity.  In  dogs,  in  which  opportunities  of  observing  the  habits 
and  effects  of  the  parasite  have  lieen  more  frequent  than  with  other  ani- 
mals, it  has  been  found  stretched  along  the  whole  length  of  the  ureter,  in 
the  bladder,  in  tlie  peritoneal  cavity,  into  whicli  it  had  i)assed  from  the 
renal  pelvis,  and  in  external  swellings  in  the  neighborhood  of  the  ])enis. 

Davaine  has  gatliered  so  many  of  the  scattered  instances  in  which  this 
worm  has  secured  its  admission  into  the  human  body  that  it  is  to  his  re- 
search that  we  are  chiefly  indebted  for  our  knowledge  of  its  clinical 
results.  From  the  year  1074  to  his  date  of  publication,  1877,  this  writer 
has  collected  seven  cases  which  he  regards  as  '"probable,"  eight  as  ''very 
uncertain,''  which  may  be  taken  to  represent  our  whole  recorded  ex- 


246  RENAL    PARASITES. 

perience  of  this  parasitic  disorder  in  the  human  subject.  Among  the 
seven  "  probable  "  cases  were  two  in  which  the  worms  had  been  passed 
by  the  urethra  only,  one  in  which  they  had  escaped  by  lumbar  fistulae, 
and  the  urethra  also,  four  in  which  they  were  found  in  the  kidney  after 
death.  Of  these  four  to  Avhich  alone  we  can  apjjeal  for  pathological  in- 
formation, there  is  but  one  in  which  the  condition  of  the  kidney  is  de- 
scribed with  any  minuteness:  in  this  case  the  secreting  structure  was 
nearly  destroyed,  and  the  weight  of  the  organ  reduced  to  about  half 
(see  p.  247).  With  animals  the  kidney  has  often  been  noticed  in  these 
circumstances  to  have  displayed  all  the  effects  of  pyelitis,  to  have  be- 
come variously  dilated,  as  happens  from  stone,  and  in  the  North  American 
mink  in  particular  to  have  become  converted  into  a  cyst,  the  walls  of 
which  are  the  seat  of  calcareous  deposit.  An  instance  has  already  been 
referred  to  in  the  dog,  in  which  worms  of  this  nature  had  passed  from 
the  renal  into  the  abdominal  cavity. 

The  instance'  relating  to  the  human  subject  in  which  stronguli  were 
discharged  through  a  lumbar  abscess  may  be  further  mentioned,  not- 
withstanding that  it  has  been  quoted  by  other  writers.  A  boy  was  cut 
for  stone  by  M.  Moublet  at  the  hospital  of  Tarascon,  and  a  large 
calculus  removed.  Four  years  later,  after  an  attack  of  partial  sup- 
pression of  urine  with  much  constitutional  disturbance,  an  abscess  was 
found  in  the  lumbar  region,  was  opened,  and  healed.  But  the  cicatrix 
after  a  time  was  undermined  by  renewed  suppuration  and  again  opened. 
From  the  opening  thus  made  a  living  strongulus  was  withdrawn  by  the 
child^s  mother,  and  a  few  hours  afterwards  another  by  M.  Moublet.  Two 
days  afterwards  two  worms  of  the  same  kind  were  passed  by  the  ure- 
thra, one  with  the  help  of  forceps,  the  second  spontaneously.  Having 
thus  got  rid  of  four  of  these  formidable  interlopers,  the  child  recovered. 

If  we  may  accept  a  case,  which,  however,  Davaine  has  shown  to  want 
corroboration,  the  concurrence  of  a  stone  with  this  parasite,  which  M. 
Moublet's  patient  presented,  is  not  singular.  A  worm  apparently  of 
this  nature  was,  as  far  back  as  the  year  1595,  found  in  the  kidney  of  a 
Belgian  archduke,  together  with  a  calculus.  Given  the  Avorm,  the  stone 
is  not  improbable  as  a  result;  some  of  the  exuvi*  might  readily  give 
ground  for  concretion." 

The  symptoms  produced  by  the  presence  of  this  parasite  in  the  kid- 
ney are  those  of  stone  aggravated  in  respect  that  rest  brings  no  relief, 
and  with  the  repulsive  addition,  if  we  accept  the  evidence  of  a  single 
instance,  of  a  sense  of  movement  in  the  renal  region.  The  symptoms 
are  gra])hically  displayed  in  a  case  related  by  M.  Aubinais^  and  quoted 
by  Davaine.  A  French  husbandman,  sixty  years  of  age,  was  seized  with 
shar[)  pains  in  the  region  of  the  right  kidney,  which  were  supposed  to  be 
nephritic.  For  three  years,  then,  in  spite  of  many  anodyne  and  other 
remedies,  these  were  incessant  and  most  severe,  and  the  man,  formerly 
somewhat  obese,  was  reduced  to  a  skeleton.  In  this  condition  of  atten- 
uation, movements  of  swelling  and  undulation,  apparently  in  the  situa- 
tion of  the  right  kidney,  could  be  felt  and  seen  through  the  thin 
abdominal  wall.  The  patient  himself  was  conscious  of  crawling  move- 
ments, or  movements  of  '''  reptation,''  as  M.   Aubinais  terms  them,  in 

'  Moublet,  Joum.  de  Med.  et  de  Chirurg.,  Juillet,  1758.  Quoted  by  Rayer, 
Davaine,  Chopart,  etc. 

'  D.  M.  Jausoiiiiis,  31ercurii  Bello-Gallici,  tome  ii.,  cite  par  Schenck. — Da- 
vaine, op.  cit.,  p.  2y5. 

^  Quoted  by  Davaine,  2d  edition,  p.  285. 


KENAL    PARASITES.  247 

the  same  position.  After  three  years  of  these  sufferings,  bed-sore.? 
formed,  and  death  was  brought  about  by  wasting  and  exhaustion.  The 
right  kidney  was  removed  twenty  hours  after  death  by  an  incision  through 
the  flank,  Undulatory  movements  were  still  perceptible  within  it,  and 
a  living  strongulus  over  seventeen  inches  long  and  nearly  a  quarter  of  an 
inch  in  thickness  (from  five  to  six  millimetres)  discovered  in  the  pelvis. 
The  tissue  of  the  kidney  was  much  altered,  its  parenchyma  in  great  part 
destroyed,  and  its  weight  reduced  by  half. 

It  is  scarcely  needful  to  dwell  further  on  the  symptoms:  severe  at- 
tacks of  hjematuria  have  in  some  instances  marked  the  presence  of 
the  worm,  but  this  symptom  has  not  been  noticed  in  all.  Temporary 
suppression  of  urine  has  occurred  apparently  in  consequence  of  its  enter- 
ing the  ureter;  in  such  a  case,  the  other  ureter  must  have  been  also  ob- 
structed, possibly  by  other  means.  This  distinction  from  stone  or  growtii 
must  be  seldom  practicable  until  either  worms  themselves  or  their  eggs 
have  been  passed.  The  passage  of  the  latter  with  the  urine,  should  the 
domestic  relations  of  the  parasite  be  consistent  with  their  production, 
ought,  considering  their  conspicuity  as  microscopic  objects,  to  furnish 
ready  means  of  detection.  As  to  treatment,  it  may  fairly  be  inferred 
that  parasiticides  are  useless.  If  in  the  bladder  or  urethra  its  removal 
will  be  indicated  ;  the  means  must  be  suggested  by  the  case  itself.  If  in 
the  kidney,  it  may  be  considered  whether  the  circumstances  are  such  as 
to  justify  nephrotomy. 

Pentastoma  Denticulatum. 

This  creature,  which  would  be  comprehended  under  the  common 
term  tick,  must  ap])areutly  be  counted  as  a  renal  parasite,  though  it  has 
no  clinical  significance  in  this  relation.  Like  many  other  parasites, 
it  presents  two  different  phases,  which  have  become  known  by  different 
names.  In  the  adult  state,  as  the  Pentastoma  tenioides,  it  lives  at  large 
in  the  nasal  cavities,  chiefiy  of  the  dog,  where  it  presents  the  shape  of  a 
maggot  or  wingless  insect,  covered  with  rings  of  mail,  varying  accord- 
ing to  sex  from  one  to  three  inches  in  length,  the  male  being  the  shorter. 
In  the  larval  state,  as  the  Pentastoma  denticulatum,  it  attains  the  length 
only  of  about  an  eighth  of  an  inch,  and  is  narrowly  confined  within  a 
cyst  which  is  imbedded  usually  in  one  of  the  abdominal  organs.  The 
animal  in  this  stage  of  its  existence,  in  which  only  its  interests  are  con- 
cerned with  those  of  the  kidney,  is  somewhat  ship-shaped  or  navicular, 
with  a  rounded  forej^art,  where  are  placed  four  booklets  or  anchors, 
with  lines  narrowing  towards  the  stern  and  sides  beset  with  fine  spines. 

The  relationship  between  the  largo  and  active  adult  and  the  minute 
and  imprisoned  offspring  appears  to  have  been  fairly  ascertained.  The 
ova  of  the  nasal  intruder,  carried  out  Avitli  mucus  or  expelled  by  sneez- 
ing, may  readily  attach  themselves  to  the  food  of  men  or  of  animals; 
thus  taken  into  the  stomach,  the  embryos  escape  and  bore,  for  which 
purpose  Nature,  with  an  impartial  consideration  of  their  necessities,  has 
provided  them  with  a  suitable  api)aratus;  they  thus  enter  various 
organs  and  tissues,  among  which  the  liver  appears  most  often  to  snpi)ly 
their  resting-place,  but  occasionally  the  lung,-  the  submucous  tisssue  of 
the  small  bowel,  and  the  kidney.  The  kidney,  so  far  as  I  know,  has 
been  mentioned  but  once  in  this  relation,  aiul  that  by  Wagner;  but  our 
knowledge  of  tlic  distribution  of  this  parasite  in  its  larval  stage  makes 
it  more  than  probable  that  this  localization  of  it  is  not  solitary,  though 


248  RENAL   PARASITES. 

otherwise  unnoticed.  The  imbedded  larvae,  or  those  of  them  which  are 
destined  for  further  development,  are  released  when  the  flesh  in  which 
they  lie  is  torn  up  by  the  dog  or  wolf,  and  thus  liberated,  sniffed  into, 
or  otherwise  enabled  to  enter  the  inquiring  nose  of  the  quadruped.  From 
this  the  completed  cycle  begins  again. 

The  embryo  having  reached  its  place  of  rest,  repeatedly  casts  its  skin 
with  rapid  growth,  and  at  last  attains  tlie  perfected  larval  form  to  whicli 
the  name  Pentastoma  deiiticulatum  has  been  given,  wliich  remains  en- 
cysted and  inactive  in  the  organ  in  which  it  has  been  imbedded  until  it  is 
introduced  to  the  upper  world  by  some  such  process  as  has  been  referred 
to.  Unlike  the  Pentastoma  constrictum,  the  presence  of  which  has  been 
associated  with  destructive  inflammation,  no  symptoms  have  been  traced 
to  the  denticulatum.  It  appears  to  be  by  no  means  uncommon  in  some 
parts  of  the  Continent,  however  rare  in  this  country.  According  to 
Frerichs,  it  is  to  be  found  in  the  liver  more  often  than  theecchinococcus; 
though  Murchison,  in  England,  long  sought  for  it  without  success.  It 
appears  to  be  especially  common  in  Brazil.' 

In  the  only  instance  in  which  the  parasite  was  recognized  in  the 
kidney,  a  small  Avhitish,  slightly  raised  oval  patch  of  flbrous  appear- 
ance, about  one-seventh  of  an  inch  in  length,  was  found  underneath  the 
capsule.  This  little  body  was  hollow  in  the  interior;  it  contained  a  yel- 
lowish mass,  which  on  examination  disclosed  the  presence  of  the  worm." 

Tetkastoma  Kexale. 

The  so-called  Tetrastoma  renale  may  be  briefly  dismissed  as  of  un- 
certain origin,  though  probably  parasitic.  A  parasite  to  which  this  name 
was  given  was  found  by  Lucarelli  in  the  urine  of  an  old  woman  who 
was  thought  to  have  symptoms  of  stone,  and  it  was  inferred  that  it  had 
come  from  the  kidney  tubes.  On  the  death  of  the  patient,  however, 
two  months  afterwards,  no  such  parasites  were  to  be  found  there  or  else- 
where.^ This  trematode  was  described  by  Delia  Chiage  as  having  a 
length  of  five  lines,  an  oval  flattened  body,  and  four  suckers  at  the  cau- 
dal extremity. 

Worms  Accidektallt  Present  ix  the  Urixary  Passages. 

Worms  belonging  to  the  alimentary  cavities  may  accidentally  enter  the 
urinary.  Oxyurides,  or  thread  worms,  may  crawl  from  the  rectum  and 
reach  the  vulva,  or  the  orifice  of  the  female  urethra,  into  which  channel 
they  may  possibly  intrude  themselves  to  be  passed  witli  the  urine. 

Other  bowel  worms,  should  they  be  found  in  the  urinary  cavities, 
must  have  come  through  a  fistulous  communication.  This  has  most 
often  been  the  case  with  regard  to  lumbrici,  animals  whicli  have  a  re- 
markable propensity  for  penetrating  into  small  holes  of  every  kind. 
Tliese  worms  have  often  thus  fatally  entrapped  tliemselves  in  buttons 
and  "hooks  and  eyes,"  which  have  been  accidentally  swallowed,  and 
others  have  penetrated  into  abscesses  and  other  cavities  opening  upon 
the  alimentary  canal.     With  regard  to  the  bladder,  a  large  number  of 

'  See  Cobbold's  Parasites,  1879.  p.  259.  Davaine,  Traite  des  Entozoaires,  1877, 
p.  cxxiv. 

'  Wagner's  description  quoted  by  Roberts,  Renal  and  Urinary  Diseases,  2d 
edition,  p.  594. 

5  Entozoa,  by  Cobbold,  1864,  p.  204. 


RENAL    PARASITES.  2^9 

instances  are  on  record  in  -whicli  these  worms  have  got  into  it  through 
fistulous  openings  and  been  passed  with  the  urine,  and  we  are  indebted 
to  Davaine  ^  for  bringing  them  together. 

Several  of  these  worms  have  at  intervals  been  expelled  or  withdrawn 
from  th6  same  urethra.  A  boy  seven  years  of  age,  after  having  reten- 
tion of  urine  for  seven  days,  perceived  the  extremity  of  a  worm  protrud- 
ing from  the  meatus,  pulled  it  out  and  was  relieved.  A  year  later  an- 
other lumbricus  presented  itself,  and  was  removed  by  the  boy's  mother. 
During  the  two  years  succeeding  the  second  removal,  many  worms  of 
the  same  sort  were  similarly  got  rid  of.  Subsequently,  many  similar 
worms  escaped  by  the  anus,  violent  pains  occurred  in  the  region  of  the 
bladder,  purulent  urine  was  discharged  with  the  stools,  and  the  patient 
sunk.  It  was  found  that  the  vermiform  appendix  was  displaced,  and 
was  adherent  to  the  bladder,  with  the  interior  of  whicli  that  of  the 
vermiform  appendix  communicated  by  a  fistulous  openiiig.  A  large 
calculus  was  found  in  the  bladder,  and  in  the  calculus  a  pin.  This  had 
probably  been  the  origin  of  the  whole  complication  ;  it  had  been  swal- 
lowed, had  entered  the  appendix,  and  thus  set  up  inflammation,  which 
had  led  to  adhesion  and  then  to  ulceration,  by  which  it  had  reached  the 
bladder  and  become  the  nucleus  of  the  stone. 

The  symptoms,  after  the  early  retention  of  urine,  were  apparently 
due  more  to  the  stone  than  to  the  worms;  indeed,  Avhere  lumbrici  have 
reached  the  bladder  from  the  bowel,  unless  they  have  entered  the  urethra 
and  caused  retention,  the  symptoms  appear  to  be  little  more  than  those 
which  commonly  attend  the  fistulous  communication. 

Another  case  is  recorded  nearly  parallel  to  that  mentioned,  in  which 
lumbrici,  passed  from  the  bladder,  were  found  to  have  reached  it  through 
an  adherent  and  perforated  vermiform  appendix.  In  this  case  also  a 
stone  was  found  in  the  bladder.  Instances  are  likewise  on  record  in 
which  a  similar  intrusion  has  occurred  by  way  of  a  fistula  between  the 
bladder  and  rectum." 

Joints  of  t^enite  have  been  known,  though  rarely,  to  have  been  simi- 
larly introduced  into  the  bladder. 

Spurious  Worms. 

An  endless  variety  of  insects,  worms,  and  vermiform  bodies  have 
been  introduced  into  the  urine  by  accident  or  design,  and  placed  upon 
record  as  urinary  parasites,  while  some  have  been  not  i)arasitic,  and 
others  neither  parasitic  nor  urinary.  Some  supposed  worms  have  clearly 
been  vermiform  coagula  from  the  ureter.  Of  other  supposititious  para- 
sites, the  extraordinary  research  of  Davaine  has  provided  a  largo  selection 
collected  from  ancient  and  modern  literature.  These  would  appear  to 
include  all  possible  and  some  impossible  insects.  These  are  variously 
described  as  winged,  provided  with  legs,  antennae,  or  eyes  of  fire,  while 
others  present  tlie  form  of  scorpions  or  the  more  familiar  shapes  of 
beetles  and  grasshoppers. 

Though  such  obvious  mistakes  are  little  likely  to  be  now  repeated, 
nevertheless  modern  days,  as  if  the  art  of  deceiving  improYed  pa?'i  passtc 
with  the  means  of  detection,  have  witnessed  such  successful  imitations 
of  urinary  parasites  as  to  pass  current  with  observers  of  approved  skill 
and  technical  accomplishment. 

'  Loc.  cit.,  p.  300. 

■  W.  Kingdon,  London  Med.-Chir.  Review,  July,  1843. 


250  RENAL    PARASITES. 

A  girl  five  years  of  age  was  supposed  to  have  passed  with  the  urine 
a  number  of  worms  of  from  four-fifths  to  two-fifths  of  an  inch  in  length. 
These  were  carefully  examined  by  Mr.  Curling,  and  described  by  him  in 
a  paper  read  before  the  Medico-Chirurgical  Society  as  a  new  urinary 
parasite  under  the  name  Dactylius  aculeatus.  For  a  time  the  discovery 
appears  to  have  remained  unquestioned,  but  there  appears  to  be  little 
reason  to  doubt  from  the  observations  of  Cobbold  and  others  that  the 
worm  was  but  a  species  of  earth-worm  known  to  frequent  flower-pots, 
and  described  under  the  name  Euchytroeus  aJbidus.  The  mode  of 
migration,  as  Cobbold  observes,  from  the  flower-pot  to  the  receptacle 
in  which  the  supposed  parasite  was  found  is  not  difficult  of  explanation. 

Two  other  spurious  urinary  parasites,  which  were  furnished  by  the 
same  patient,  and  have  been  dignified  by  the  names  Sjriroptera  Iwminis 
and  Diplosoma  crenatum,  need  a  passing  mention,  as  connected  with 
one  of  the  most  remarkable  of  those  female  simulations  which  are  so 
incomprehensible  to  the  masculine  mind.  The  primary  victim  and 
sponsor  of  the  imposture  was,  together  with  Mr.  Barnett,  the  acute  and 
sceptical  Lawrence,  who  brought  the  case  as  one  of  parasitic  disease  be- 
fore the  Medico-Chirurgical  Societ}^  A  3'oung  woman  had  obstinate  re- 
tention of  urine  with  symptoms  such  as  commonly  indicate  stone  in  the 
bladder.  The  catheter  Avas  used  as  frequently  as  such  a  patient  could 
desire.  She  was  sounded  for  stone  in  vain,  but  described  a  "  fluttering" 
in  the  bladder,  presently  succeeded  by  the  withdrawal  of  several  small 
worms  which  had  become  curiously  entangled  in  the  eye  of  a  catheter 
retained  for  a  time  in  the  urethra.  "Worms,  or  what  passed  for  them, 
were  evacuated  actually  or  ostensibly  to  the  number  of  above  800.  These 
were  of  two  kinds:  small  veritable  worms,  which  were  desci'ibed  as 
Spiroptcra  hominis,  and  larger  vermiform  bodies,  which  Dr.  Arthur 
Farre,  after  elaborate  examination,  entitled  Diplosoma  crenata.  Speci- 
mens of  both  were  forwarded  to  Continental  museums ;  the  discovery 
was  for  a  time  accepted,  and  two  parasites  were  added  to  the  list  of 
these  concealed  enemies  of  mankind.  The  small  worm,  however,  truly 
parasitic  though  it  was,  proved  to  belong  not  to  the  human  being  but 
the  fish;  it  was  identified  beyond  doubt  by  Dr.  Schneider  as  the  Filaria 
piscium,  a  worm  of  common  occurrence  in  the  haddock  and  cod  ;  while 
the  Diplosoma  crenata,  as  Cobbold  has  shown,  almost  certainl}'  consists 
of  slices  of  haddock's  roe.  The  smaller  worms,  from  half  an  inch  to  an 
inch  in  length,  sometimes  made  their  appearance  alive,  and  lived  in  the 
urine  for  tliree  days.  The  report  is  explicit  as  to  the  circumstances  that 
most  or  many  of  these  were  actually  discharged  through  or  withdrawn 
with  a  catheter,  so  that  it  is  certain  that  some  at  least  actually  came 
from  inside  the  bladder.  The  patient,  therefore,  must  have  introduced 
not  only  sham  worms,  but  loathsome  living  parasites,  within  the  pene- 
tralia of  her  own  body.  The  satisfaction  she  derived  from  so  doing 
must  have  been  considerable  if  it  bore  any  proportion  to  the  sufferings 
entailed:  these  comprised  the  utmost  distress  from  strangury,  typhoid 
prostration,  arid  a  large  abscess  which  burst  into  the  vagina  after  con- 
stitutioiuil  disturbance  which  well-nigh  proved  fatal.' 

'See  "Case  of  a  Woman  who  voided  a  large  number  of  Worms  by  the 
Urethra,"  by  W.  Lawrence,  Med.-Chir.  Trans.,  vol.  ii.  p.  383.  Dr.  Arthur  Farre, 
Archives  of  Medicine,  vol.  i.  p.  2!t().  Also  Dr.  Farre's  article  "Worms,"  Libntry 
of  Medicine,  vol.  v.  p.  241.  Di-.  Beale,  Kidney  Diseases,  etc.,  3d  edition,  p.  399. 
Cobbold,  Entozoa,  pp.  406,  409. 


OHAPTEE    XIX. 
CHYLURIA. 

HiSTOEY   AND    ClINICAL   AsPECT. 

The  disorder  which  is  known  by  this  name,  and  characterized  by  the 
passing  of  urine,  which  has  been  regarded  as  chylo-serous,  chylous,  or 
haematochylous,  or  more  barely  described  as  oleo-albuminous  or  albu- 
minous and  fatty,  is  one  which  both  in  its  cause  and  in  its  symptoms 
presents  itself  with  remarkable  isolation  and  distinctness.  The  leading 
symptom^  is  the  admixture  with  the  urine  of  a  fatty  emulsion  which  has 
all  the  properties  of  chyle;  while  its  most  common  if  not  its  only  cause 
is  the  presence  in  the  living  body  of  parasitic  worms,  of  which  the  adults 
appear  to  be  located  in  the  absorbents,  while  the  progeny  find  their 
habitation  in  the  blood-vessels,  and  their  element  in  the  blood. 

The  disorder  is  one  which  has  long  excited  curiosity;  and,  indeed,  it 
seems  to  have  received  its  name  almost  prophetically  at  a  time  when, 
neither  chemically  nor  by  the  microscope,  could  the  chylous  admixture  be 
ascertained.  John  Peter  Frank,  in  his  fifth  book,  De  Frofluviis,  which 
represents  the  state  of  knowledge  in  the  year  1794,  speaks  of  diabetes 
chylosus,  or  flux2(s  per  renes  cmliaciis.  It  is  needless  to  interpolate  that, 
in  the  language  of  tlie  older  writers,  a  coeliac  flux  was  an  escape  of  what 
they  thought  to  be  chyle.  Further  than  this,  Frank  uses  the  actual 
term  chyluria,  and  distinguishes  between  this  condition  and  one  of 
purulent  admixture;  though  it  is  not  impossible,  and  is  indeed  suggested 
by  his  description,  that  urine  which  was  thus  regarded  as  chylous  may 
have  been  merely  phosphatic.  He  attributes  it  especially  to  persons, 
otherwise  in  good  health,  who  take  active  exercise  after  a  full  meal;  a 
familiar  cause  of  phosphatic  urine,  and,  it  may  be  added,  no  less  an  in- 
centive to  a  chylous  state  of  that  secretion  in  a  chylurious  subject. 

Cruickshank,'  also,  in  the  year  1806,  speaks  of  urine  of  a  white  color, 
as  was  supposed  from  chyle;  but  since  he  attributes  this  to  children  who 
are  subject  to  worms,  it  is  probable  that  he  also  refers  merely  to  urine 
milky  with  })hosphates.  Thus  chyle,  although  conjecturally  spoken  of 
as  passed  with  the  urine,  does  not  appear  to  have  been  conclusively 
recognized  in  that  relation  until  the  time  of  Prout,^  who,  in  the  year 
1821,  described  some  urine  as  so  closely  resembling  chyle  in  all  respects 
that,  had  it  been  brought  before  him  as  a  specimen  of  that  fluid,  he 
might  not  have  discovered  the  imposition.  This  observer,  however, 
though  he  gives  a  clinically  excellent  sketch  of  the  disease,  scarcely  at- 
tained to  an  adequate  idea  of  its  nature.     He  saw  in  it  only  an  arrest  of 

'  Experivients  on  Urine  and  Sugar.  Appended  to  Rollo's  work  on  Diabetes, 
p.  451. 

"  An  Inquiry  into  the  Nature  and  Treatment  of  Oravel,  etc.     Edit.  i.  p.  41. 


252  CHYLURIA. 

assimilation,  and  the  discharge  by  the  kidneys  of  chyle  which  had  failed 
to  undergo  its  proper  transformation  into  blood.  In  describing  the 
urine  as  chylo-serous  rather  than  chylous,  he  pointed  to  its  supposed 
analogy  Avith  the  disorder  characterized  by  serous  urine,  of  which  he  held 
this  to  be  a  mere  variety.  Dr.  Bence  Jones  '  thought,  with  Prout,  that 
the  chylous  discharge  was  derived  from  the  blood,  but  attributed  it,  not 
to  defective  assimilation,  but  to  some  slight  alteration  in  the  structure 
of  the  kidney,  which  allowed  the  constituents  of  chyle  to  transude  from 
the  blood-vessels,  and  which  remained  without  repair  for  years.  He 
thought  the  leak  could  be  closed  by  means  of  gallic  acid,  and  detailed  a 
case  with  much  minuteness  which  afforded  this  inference.  The  cure, 
however,  was  only  temporary,  and  the  habit  of  the  complaint  to  inter- 
mit for  long  periods,  independently  of  treatment,  must  make  us  cau- 
tious in  dealing  with  the  effects  of  remedies. 

The  views  held  by  Prout  and  Bence  Jones  were  not  very  different 
from  those  expressed  at  a  later  date  by  Dr.  Waters,'^  who  believed  that 
''the  main  pathological  feature  of  the  complaint  was  a  relaxed  con- 
dition of  the  capillaries  of  the  kidneys,"  which  allowed  fibrin  fat  and 
corpuscles  to  filter  from  the  blood-vessels  into  the  urine,  the  leading 
idea  up  to  this  time  being  that  the  addition  to  the  urine  was  supplied  by 
the  blood;  a  view  which,  besides  other  objections,  is  inconsistent  with 
the  fact,  which  frequent  observations  have  placed  beyond  doubt,  that 
though  the  urine  be  milky  the  blood  is  not;  the  peculiarly  subdivided 
fat  which  is  a  characteristic  of  chyle  and  of  chylous  urine  being  uni- 
formly absent  from  the  blood. 

Perhaps  it  may  be  fairly  said  that  until  quite  recently,  though  many 
examples  have  been  placed  upon  record  and  the  clinical  characters  of  the 
disease  well  illustrated,  yet  no  clear  light  has  been  thrown  upon  its 
pathology  further  than  was  apparent  to  Prout. 

The  important  suggestion  that  the  urinary  change  was  produced  by 
a  direct  discharge  of  the  contents  of  the  absorbents  into  the  urine  was 
made  by  M.  Gubler,^  and  the  derangement  attributed  to  a  varicose  state 
of  the  renal  lymphatics,  analogous  to  that  which  on  the  surface  of  the 
body  had  been  known,  especially  within  the  tropics,  to  be  attended  Avith 
a  lymphatic  discharge.  Later  this  view  presented  itself  to  Dr.  Vandyke 
Carter,  of  Bombay,  who,  in  an  admirable  paper  read  before  the  Medico- 
Chirurgical  Society,  went  far  to  prove  the  change  to  be  due  to  the  direct 
discharge  of  chyle  into  the  urinary  system.  He  attributed  this  to  some 
morbid  communication  between  the  lacteals  and  lymphatics  of  the  lum- 
bar region  with  the  pelvis  of  the  kidney,  ureter,  or  bladder. 

Lastly,  Dr.  Lewis,  of  Bengal,  made  the  striking  discovery  which  as- 
sociates the  mechanical  derangement  with  the  presence  in  the  blood,  in 
the  kidneys,  and  elsewhere,  of  vermiform  parasites;  a  discovery  to  which 
important  additions  have  been  made  by  other  observers. 

AVithout  further  preface  I  will  proceed,  with  the  aid  of  a  series  of 
cases  collected  from  different  sources,  including  several  under  my  own 
care,  to  sketch  the  more  i)rominent  features  of  the  disease  as  in  the 
present  day  it  presents  itself  to  our  view.  The  definition  lies  in  the 
state  of  the  urine,  and  is  implied  in  the  name.  Though  the  chylous 
admixture  appears  to  be  commonly  associated  with  a  tropical  parasite, 

'  Lectures  on  Pathology  and  Therapeutics,  1868,  p.  256. 
^  Med.-Chir.  Trans,  vol.  xlv.  p.  221  (1862). 
^  Gazette  Medicate  de  Paris,  1858,  p.  646. 


CHYLURIA.  253 

and  the  disorder  correspondingly  frequent  in  such  regions,  yet  it  is  clear 
that  beside  the  endemic  we  have  what  may  be  termed  an  accidental  form 
of  the  disease,  which  occurs  in  persons  who  have  never  left  our  own 
country;  either  because  the  parasite  may  be  engendered  as  well  in  tem- 
perate as  in  tropical  places,  or  because  the  necessary  communication  be- 
tween the  channels  of  chyle  and  those  of  urine  may  be  made  otherwise 
than  by  its  agency. 

To  touch  first  upon  the  geographical  distribution  of  the  disease,  I 
find  that  among  72  cases  (67  placed  on  record  by  various  writers  to  whom 
reference  has  mostly  been  made  in  the  course  of  this  chapter,  and  5 
within  my  own  knowledge)  there  are  5  in  which  tlie  disease  was  une- 
quivocally of  English  origin;  59  in  which  it  had  originated  in  tropical 
or  subtropical  regions,  using  the  last  expression  somewhat  liberally,  so 
as  to  include  that  large  proportion  of  the  earth's  surface  which  lies  be- 
tween 40°  of  north  latitude  and  40°  of  south  latitude;  from  the  south  of 
Europe,  that  is,  to  the  south  of  Australia;  and  8  in  which  the  place  of 
origin  was  uncertain,  among  which  is  classed  one  to  be  presently  related, 
of  which  the  subject  had  lived  in  India,  but  had  been  in  England  for 
five  years  when  the  symptom  appeared. 

First,  as  to  tlie  cases  of  European  beginning.  One,  under  my  own 
observation,  was  in  tlie  person  of  a  man  who  was  born  in  Suffolk,  had 
lived  almost  all  his  life  in  London,  and  never  left  England.  Dr.  Beale 
relates  a  case,  which  was  witnessed  by  Mr.  Cubitt,  of  which  the  subject, 
a  woman  aged  50,  was  a  "  native  of  Norfolk,  in  which  county  she  had 
always  resided."  Another  case,  from  the  same  county,  that  of  an  agri- 
cultural laborer,  57  years  of  age,  is  reported  by  Dr.  Dale  in  the  "Lan- 
cet" for  July  23d,  1877.  The  man  was  a  patient  in  the  Norfolk  and 
Lynn  Hospital,  and  had  never  left  Great  Britain.  It  is  of  interest  to 
observe  in  passing  that  this  patient  was  the  subject  of  a  fluctuating 
swelling  on  the  left  of  the  spine,  which  was  thought  to  be  a  chronic 
abscess,  but  disappeared.  The  fourth  instance,  that  of  a  woman  who 
was  born  in  the  neighborhood  of  Manchester,  and  had  never  lived  out  of 
the  country,  is  related  by  Dr.  Koberts.  The  changed  appearance  of  the 
urine  in  this  case  was  first  observed  after  delivery — not  the  only  case  in 
which  a  relation  has  been  apparent  between  chyluria  and  gestation. 
Another  instance,  not,  however,  of  persistent  chyluna,  is  mentioned  by 
the  same  author,  in  which  a  transiently  chylous  condition  of  the  urine, 
associated  with  a  chylous  discharge  from  the  surface  of  the  al>domen, 
was  noticed  in  a  man  '^always  a  resident  in  Lancashire."  Another  in- 
digenous case  is  recorded;  the  young  woman  wlio  was  tlie  subject 
of  it  was  born  in  a  suburb  of  London,  and  had  never  left  England, 
or  indeed  been  far  from  home.  These  instances,  a  minority  though 
they  be,  are  enough  to  show  that  the  disorder  is  not  necessarily  of  tropi- 
cal or  subtropical  origin.  But  how  often  it  is  one  or  the  other  is  shown 
by  the  fact  that  among  sixty-five  instances  in  which  the  place  of  origin 
was  known,  sixty  pertained  to  persons  who  had  been  born  in  or  had 
visited  the  latitudes  between  that  of  South  Australia  and  that  of  Gibral- 
tar, and  had  probably  contracted  the  disease  within  these  limits  !  We 
have  evidence  of  its  origin  in  many  parts  of  India;  it  is  well-known 
in  each  of  tlie  three  Presidencies;  in  China;  in  the  West  Indies,  with 
especial  mention  of  Barbadoes,  Trinidad,  and  Demerara;  in  Cuba,  Ber- 
muda, Brazil,  frequently  in  Mauritius,  in  the  Isle  of  Bourbon,  and 
further  south,  so  as  to  include  the  southern  parts  of  Australia.  We 
have,  indeed,  received  important  information  from  Brisbane,  where  the 


254-  CHYLURIA. 

disorder  is  well  known.  It  appears  to  prevail  especially  in  insular  and 
maritime  districts,  and  with  this  preference  to  include  within  its  range 
portions  of  each  of  the  four  quarters  of  the  globe  and  of  Australia,  It 
may  be  doubted  whether  any  parasitic  or  endemic  disease  is  equally 
widely  scattered.  For  our  extensive  knowledge  of  it  we  are  indebted  to 
the  extent  of  our  empire  and  the  wandering  propensities  of  our  race. 
Within  its  chosen  localities  it  attacks,  without  exemption,  natives,  per- 
sons of  European  birth,  Jews,  and  negroes.  As  to  sex,  of  the  seventy- 
two  cases  mentioned  the  subjects  were  of  the  male  sex  in  forty-one,  of 
the  female  in  thirty-one  instances.  The  preponderance  of  males  in  our 
records  may  be  due  to  the  more  numerous  exposures  of  men,  among 
Europeans,  as  the  more  frequent  travellers,  to  the  endemic  influence 
which  causes  the  disease,  while  perhaps  among  Orientals  women  may  be 
less  accessible  to  medical  observation  than  are  men.  Dr.  Lewis,  indeed, 
tells  us  that  at  Calcutta  the  patients  sulfering  from  chyluria  have  for 
the  most  part  been  women;  but,  on  the  other  hand,  it  is  to  be  noted 
that  the  larger  number  of  instances  he  has  recorded  were  of  the  male 
sex,  while  of  the  cases  referred  to  by  Dr.  Vandyke  Carter,  whose  field 
of  observation  was  Bombay,  all  were  males.  The  disorder  is  probably 
divided  with  much  impartiality  as  regards  sex. 

With  regard  to  age  no  period  of  life  appears  to  be  exempt  from  its 
attacks.  Prout  mentions  an  instance  at  the  age  of  eighteen  months.  I 
was  consulted  touching  the  son  of  an  Indian  surgeon,  who  was  attacked 
with  the  disease  before  completing  his  fifth  year.  A  case  is  known  to 
have  proved  fatal  at  the  age  of  twelve.  After  this  period  the  frequency 
of  the  disorder  appears  to  increase;  it  is  common  in  adolescence  and 
middle  age,  and  not  unknown  in  advanced  life.  Eayer'  refers  to  the  case 
of  an  old  woman,  a  native  of  the  Isle  of  Bourbon,  who  had  the  disease, 
with  one  short  intermission,  from  the  age  of  twenty-five  to  that  of 
seventy-eight,  when  it  was  still  unconcluded. 

The  course  of  the  disorder,  and  its  symptoms  so  far  as  there  are  any, 
may  be  broadly  sketched.  Putting  aside  the  condition  of  the  urine,  it 
ma}'  be  said  that  of  sjjecial  or  distinguishing  symptoms  there  are  none. 
It  is  remarkable  even  that  the  urinary  organs  themselves  seldom  show 
any  signs  of  disturbance.  There  is  sometimes  pain  in  the  back  of  a 
somewhat  indefinite  kind,  but  there  are  no  dropsical,  uraemic,  or  any 
other  constitutional  signs  of  renal  disorder,  and  what  perhaps  is  more 
surprising,  there  is  no  frequency  of  micturition  or  evidence  of  vesical 
irritation.  Such  symptoms  as  are  produced  are  those  of  inanition;  in 
one  case,  wasting,  pallor,  loss  of  strength,  and  depression  of  spirits  were 
marked  so  long  as  the  discharge  was  unchecked,  at  once  mitigated  with 
its  control.  Tlie  catamenia  were  irregular;  the  temperature  of  a  some- 
what low  average.  The  constitutional  results  of  the  disorder  appear  to 
be  produced  solely  by  the  waste  of  nutritive  material.  Some  persons 
bear  the  loss  better  than  others,  and  in  several  instances  the  general 
health  seems  to  have  been  perfect;  the  patient  has  remained  of  robust 
aspect,  and  displayed  no  failure  in  strength;  women  thus  affected  have 
repeatedly  borne  children.  As  it  happens  when  nutrition  is  impaired 
in  other  ways  by  waste  or  want,  tuberculosis  often  supervenes,  and  in- 
deed has  been  found  in  most  of  the  cases  Avhere  chyluria  has  ended 
fatally.  Whether  the  tubercles  are  always  strictly  of  this  nature,  or 
whether,  as  is  possible,  they  may  in  some  cases  have  been  local  results 

'  Quoted  from  Quevenne.     Rayer,  Maladies  des  Reins,  vol.  iii.  p.  427. 


CHYLUKIA. 


255 


of  the  parasite  with  which  the  disease  is  connected,  we  have  no  evidence 
to  show. 

In  the  condition  of  the  urine  lies  the  definition  of  the  disease;  and, 
indeed,  so  solely  is  its  recognition  dependent  upon  the  state  of  this  secre- 
tion, and  so  little  may  disturbances  of  any  other  sort  obtrude  themselves 
that,  as  Dr.  Bence  Jones  observes,  were  a  patient  blind  he  might  not 
know  himself  to  be  ill. 

The  urine  becomes  milky  in  appearance,  so  as  to  resemble  rich  and 
creamy  milk.     The  milky  admixture  has  no  tendency  to  subside,  but 


Chylous  urine  showing  molecular  base.    X600  diameters. 

will  remain  apparently  in  uniform  suspension  for  many  days.  This 
peculiarity  is  due  to  the  presence  of  fat  in  a  state  of  molecular  or  im- 
measurably fine  subdivision.  Occasionally  oil  globules  have  been  de- 
tected as  such,  but  this  is  rare.  Usually  the  fat  appears  in  a  delicately 
granular  shape  as  represented,  and  sometimes  in  so  fine  an  emulsion 
that  though  the  milkiness  is  evident  enough,  yet  under  the  microscope 
nothing  more  can  be  discerned  than  an  indefinite  turbidity.  The  fat 
sometimes  collects  on  the  surface  in  the  shape  of  cream  or  creamy  flakes. 
The  amount  of  fat  or  of  milkiness  in  chylous  urine  depends  closely  upon 


256 


CHYLURIA. 


food,  the  urine  of  digestion  containing  this  addition  most  abundantly, 
that  of  fasting  containing  less  or  even  none  at  all. 

Besides  the  fat,  blood  is  a  nearly  constant  constituent  of  chylous 
urine.  This  often  gives  a  delicate  i^iukish  tint  to  the  fluid,  though  this 
tint  is  less  deep  than  would  be  expected  from  the  quantity  of  blood  in- 
volved, the  red  color  being  covered  by  the  Avhite  opacit}-.  On  standing, 
however,  the  corpuscles  fall  as  a  bright  bloody  sediment. 

It  has  been  observed  that  whether  wholly  derived  from  blood  or 
otherwise,  the  pinkish  tint  of  the  chylous  clot  deepens  on  exposure  to 
air,'  a  circumstance  which  points  the  resemblance  between  the  urinary 
admixture  and  the  sujierficial  discharge  from  absorbent  glands,  Avhich 
has  in  some  instances  been  associated  with  it.  A  more  distinguishing 
peculiarity  of  chylous  urine  is  its  habit  of  spontaneous  coagulation; 
shortly  after  expulsion  it  will,  if  rich  in  its  characteristic  addition,  set 
into  a  tremulous  jelly  which  has  been  likened  to  blanc-mange,  and  which 
will  after  a  time  break  into  a  mixture  of  liquid  and  flaky  coagula.  The 
gelatinizing  process  sometimes  takes  place  in  the  bladder,  and  the  clots 
have  often  formed  troublesome  obstacles  in  the  urethra. 

Some  observations  upon  chylous  urine,  which  need  not  be  recapitu- 
lated here,  are  given  with  cases  under  my  own  care,  subsequently  related. 

Dr.  Beale  describes  the  urine  passed  in  the  morning 'by  Mr.  Cubitt's 
patient  as  having  the  appearance  of  fresh  milk.  It  became  clear  on  the 
addition  of  an  equal  volume  of  ether.  The  reaction  was  neutral,  the 
specific  gravity  1.013.  A  second  specimen  of  the  same  patient's  urine, 
jaassed  during  the  same  day,  which  was  not  albuminous  nor  milky  though 
slightly  turbid,  was  also  examined.  It  had  a  specific  gravity  of  1.010.  a 
reaction  very  slightly  acid. 

Analysis  of  1000  parts  of  Chylous  and  Xon-chylons  Urine  passed  hy  the 
same  Patient  on  the  same  day.     By  Dr.  Beale. 


Chylo 

us. 

Xon- 
chyloiis. 

AVater 

947.4 
.52.6" 

7.73 
13.00 

11.66" 

9.20) 
2.70  - 
2.00  1 
1.65 

4.66 

13.9 

i 
1 

978  8 

Solid  matter 

21  2 

Urea  

6  9.") 

Albumin 

Uric  acid 

Extractive  matter  with  uric  acid. ...    

Fat  insoluble  in   hot  and  cold  alcohol  but  soluble  in 
ether 

.lo 
7.31 

Fat  insoluble  in  cold  alcohol 

Fat  soluble  in  cold  alcohol 

Alkaline  sulphates  and  ciilorides 

Alkaline  phosphates  ) 

.0 

5.34 
1.45 

Earthy  phosphates      [ 

.15 

The  milky  urine  contained  no  oil  globules.  The  fatty  matter  was 
equally  diffused  throughout  in  a  molecular  form.  By  the  highest  powers 
of  the  microscope  only  very  minute  granules  could  be  detected  which  ex- 
hibited molecular  movements.^ 


'  Dr.  Vandyke  Carter.  Med.-Chir.  Trans.,  vol,  xlv,  p,  192, 
'  Beale,  Kidney  Diseases,  etc.,  third  edition,  p.  301. 


CHYLURIA.  257 

In  Dr.  Beale's  analysis  the  chylous  urine  differs  from  the  non-chy- 
lous  chiefly  in  the  presence  of  albumin  and  fat,  the  larger  proportion  of 
phosphates  and  the  smaller  of  sulphates  and  chlorides.  Occasionally, 
as  in  a  case  published  by  Dr.  Bence  Jones,'  the  oil  has  been  known  to 
take  a  globular  form,  collecting  on  the  surface  in  this  shape,  and  leaving 
the  bulk  of  the  fluid  clear.  Even  in  this  instance,  however,  as  in  others, 
the  fat  was  usually  finely  divided  and  evenly  diffused. 

Corpuscles  indistinguishable  from  those  of  chyle  have  also  been 
found.  Dr.  V.  Carter,  in  the  case  of  a  Hindoo  who  had  also  a  chylous 
discharge  from  the  scrotum,  points  to  the  resemblance  between  the 
superficial  and  the  urinary  discharge.  Both  coagulated  on  exposure, 
and  assumed  an  increasingly  pink  color.  In  the  superficial  discharge 
besides  red  corpuscles  were  bodies  ''resembling  the  lymph  corpuscles  of 
blood."  In  the  urine,  together  with  red  corpuscles,  were  "granular 
cells  much  larger  than  these,  and  showing,  on  the  addition  of  acetic 
acid,  three  or  four  nuclei  in  their  interior;  they  were  in  short  chyle  cor- 
puscles/*   I  must  also  draw  attention  to  large  rolling  cells  of  globular 


?m       ^ 


a"  '  '^■ 


Large  globular  cells,  probably  vesical,  from  chylous  urine.     X  350  diameters. 

form  and  epithelial  type,  which  resemble  some  which  belong  to  the 
bladder  so  nearly,  that  it  is  at  least  probable  that  they  have  this  origin. 
I  have  never  had  opportunities  of  watching  a  case  of  chylous  urine  with- 
out finding  these  cells  repeatedly  and  abundantl}^  in  men  as  well  as  in 
women.  If  they  be  vesical  tliey  afford  a  pathological  indication  of  some 
importance.  Next  to  the  fat  the  most  remarkable  constituents  of 
chylous  urine  is  the  fibrin,  conferring  as  it  does  the  power  of  spontane- 
ous coagulation.  In  Dr.  Bence  Jones's  case  the  urine  could  not  be  got 
out  of  the  bottle  until  the  coagulum  had  been  broken  up  by  agitation. 
A  patient  of  mine  who  had  passed  cliylous  urine  in  India,  described  it  as 
retaining  for  a  time  the  sliape  of  tlie  vessel  in  which  it  liad  solidified,  like 
jelly  turned  out  of  a  mouhl;  and  the  same  phenomenon  was  observed  in 
another  case,  tlie  urine  falling  out  of  its  receptable  in  a  ju'iik  tremulous 
mass  like  a  large  jelly-fish.  The  coagulation  sometimes  takes  place  in 
the   bladder  with   consequent  difficulty  in   expulsion;  clots   sometimes 

'  Med.-Chir.  Trans.,  vol.  xxxiii.  p.  314. 
17 


258  CHYLURIA. 

stick  in  the  urethra,  or  have  to  be  drawn  from  its  orifice.  The  fibrin, 
however,  is  not  alwa3'S  present  in  chylous  urine,  or  at  least  not  in  suf- 
ficient quantity  to  show  itself  by  coagulation.  The  fibrin  is  most  de- 
ficient wliere  the  molecular  base  is  most  abundant.  The  chyle  in  its 
passage  from  the  bowel  to  the  thoracic  duct  becomes,  according  to  Dr. 
Vandyke  Carter,  increasing  fibrinous  in  its  course,  and  the  varying 
amount  of  fibrin  and  fat  in  chylous  urine  he  explains  on  the  hj^othesis 
that  in  different  cases  the  chyle  which  enters  the  urine  is  withdrawn  at 
different  stages  in  the  course  of  the  absorbents. 

The  fibrinous  constituent  of  chylous  urine  has  never  been  found  in 
the  form  of  casts,'  though  these  shapes  have  been  sought  by,  I  believe, 
every  observer  of  late  years  who  has  written  upon  the  subject.  This 
alone  is  suggestive  of  a  view  which  is  corroborated  by  many  other  cir- 
cumstances of  the  disease,  that  the  chylous  admixture  reaches  the  urine 


Large  globular  cells  found  in  chylous  urine.      X  600  diameters. 


© 


o 

n        O        O        O 
o 


^  o 


®  ^     m^  & 


Large  globular  cells  from  chylous  urine.     X   600  diameters.    From  case  of  a  man  50  years  of 
age,  a  native  of  Suff  ilk,  who  had  never  left  England.     The  molecular  base  was  very  abundant. 

otherwise  than  by  the  renal  tubes.  The  faults  of  the  urine  appear  to  be 
essentially  those  of  addition.  Taking  from  it  the  constituents  of  chyle, 
the  characters  become  those  of  health  or  depart  from  them  only  to  the  ex- 
tent of  an  impoverishment  which  leaves  the  urine  still  sufficient  for  the 
relief  of  the  system.  The  disease  is  not  productive  of  uremia  or  any  effect 
of  renal  deficiency.  And  that  the  urine  must  sometimes  fall  short  in  its 
essential  ingredients  is  as  evident  as  that  the  materials  which  should  go 
to  form  them  are  discharged  in  other  shapes. 

In  a  case  Avhere  the  urea  was  estimated  for  twenty-four  hours,  its 
amount  was  found  to  be  little  more  than  15  grammes,  while  in  relation 

'  I  once  found  two  hyaline  casts  in  a  case,  but  as  none  were  ever  seen  again, 
though  the  disease  persisted,  it  was  inferred  that  they  were  due  to  some  passing 
and  accidental  condition  and  furnished  only  an  apparent  exception  to  the  state- 
ment in  the  text. 


CHYLURIA.  259 

to  the  weight  of  tlie  body  the  amount  should  have  been  about  22  grammes. 
In  Dr.  Bence  Jones's  case  the  iirea  amounted  to  13.26  in  1000  parts;  the 
salts  to  8.01,  a  diminution  in  both  particulars.  Dr.  Beale's  observations, 
as  already  quoted,  show  the  same  change  in  a  greater  degree.  Instances, 
however,  have  been  published,  one,  for  example,  by  Dr.  Golding  Bird,' 
in  which  no  want  of  urea  appeared.  Uric  acid  crystals  have  been  fre- 
quently noticed.  They  were  abundant  in  one  of  the  cases  under  my  own 
observation. 

Perhaps  the  most  important  inference  to  be  drawn  from  the  state  of 
the  urine  in  this  disease  is  one  for  which  we  are  chiefly  indebted  to  Dr. 
Vandyke  Carter.  Rayer  long  ago  demonstrated  experimentally  that 
when  chyle  and  urine  were  mixed  together  a  liquid  closely  resembling 
the  chylous  urine  of  disease  was  produced.  He,  however,  does  not  seem  to 
have  inferred  that  the  morbid  process  involved  any  such  direct  mingling. 
Dr.  Carter  showed  how  minutely  chylous  urine  corresponds  with  a  mix- 
ture of  normal  chyle  and  normal  urine,  and  insists  that  the  disorder  is 
produced  by  a  direct  admixture  of  the  contents  of  the  absorbent  with 
those  of  the  urinary  channels.  Fibrin  is  absent  from  the  early  course 
of  the  lacteals,  to  be  acquired  in'the  mesentery;  so  chylous  urine  is  some- 
times coagulable  and  sometimes  not,  as  if  the  admixture  were  derived 
at  different  points  in  the  route  of  the  chyle.  Again,  the  proportions 
which  the  albumin  and  the  fat  bear  to  each  other  in  chylous  urine  are 
the  same  which  they  have  been  found  to  display  in  chyle  itself;  in  one 
case  of  chylous  urine  the  albumin  and  the  fat  were  equal,  in  another 
the  albumin  was  twice  as  much  as  the  fat;  both  these  proportions 
have  been  found  in  chyle.  There  are  further  points  of  resemblance  or 
rather  indications  of  iilentity  in  the  molecular  base  common  to  both, 
and  present  in  no  other  fluid;  in  the  corpuscles  indistinguishable  from 
those  of  chyle  which  have  been  found  in  chylous  urine;  and,  lastly,  in 
the  peculiar  deepening  of  color  under  exposure,  which  both  fluids  have 
been  known  to  present. 

The  urine  is  sometimes  rather  lymphous  than  chylous;  the  molecular 
base,  even  Avith  well-marked  chyluria,  is  not  always  present;  the  urine 
sometimes  remains  perfectly  transparent,  but  becomes  loaded  with 
transparent  jelly,  not  easily  distinguishable  from  the  fluid  itself. '^  In 
such  cases  fat  is  probably  entirely  absent,  as  if  tlie  contents  of  the 
lymphatics  instead  of  the  lacteals  had  been  poured  into  the  urinary 
channels. 

The  disease  is  of  indeterminate,  always  long,  duration,  sometimes 
extending,  usually  with  intermissions,  over  a  considerable  proportion  of 
ordinary  life.  Dr.  EUiotson  mentions  a  lady  then  sixty-four  years  of 
age,  who  had  had  the  disorder  interruptedly  for  twenty-eight  years;  and 
I  have  already  referred  to  Quevenne's  case  of  a  woman  who  had  it  from 
the  age  of  twenty-five  to  that  of  seventy-three  without  interval,  and  at 
seventy-eight  was  still  suffering  from  it. 

Looking  at  cases  of  which  the  history  has  been  closed  by  death,  we 
find  that  within  the  experience  of  EUiotson  a  woman  died  at  the  age  of 
thirty,  having  had  the  complaint  for  twenty  years ;  in  that  of  Lewis, 
one  in  whom  it  proved  fatal  together  with  general  tuberculosis  after  six- 
teen years,  with  however  an  intermission  of  half  the  time.     The  same 

'  Urinary  Deposits,  5th  edit.,  p.  420. 

'  Goodeve's  case.  Trans.  Med.  and  Phys.  Soc.  of  Calcutta,  vol.  viii.  Quoted 
by  Dr.  V.  Carter. 


260  CHYLURIA. 

observer,  however,  mentions  an  instance  in  Avliich  it  proved  fatal  at  the 
age  of  sixteen.  In  this  instance  the  disorder  was,  as  proved  by  post- 
mortem examination,  uncomplicated.  Prout  records  a  case  in  which  it 
proved  fatal  at  the  age  of  fifteen,  together  with  some  inflammatory  con- 
dition of  the  bowels. 

It  is  a  habit  of  the  disorder  to  be  dormant  or  make  long  intermissions 
often  without  obvious  reason,  and  as  capriciously  to  return.  A  lady, 
whose  disease  had  presumably  originated  in  India,  showed  no  symptoms 
of  it  until  five  years  after  her  return  to  England.  With  Dr.  Elliotson's 
patient  also,  who  had  probably  acquired  the  seeds  of  the  disease  in  India, 
it  did  not  attract  her  observation  until  nine  years  after  her  return  to 
Europe;  it  then  continued  for  seventeen  months,  disappeared  after  bath- 
ing in  the  sea,  and  remained  absent  for  thirteen  years  ;  it  reappeared 
after  an  attack  of  infiammation  of  the  lungs,  which  had  been  treated  by 
calomel  and  bleeding,  and  afterwards  held  its  ground  with  shorter  but 
still  with  occasional  intervals.  One  of  these  ensued  upon  violent  grief, 
another  accompanied  the  formation  of  a  carbuncle,  and  another  occurred 
together  with  a  second  attack  of  pulmonary  inflammation.  Dr,  Lewis 
refers  to  a  native  of  Madras  who  had  six  attacks,  each  of  about  two 
months'  duration,  within  the  space  of  two  years  and  a  half. 

The  chylous  condition  has  also  its  lesser  variations,  being  influenced 
by  food,  posture,  exercis3,  abdominal  pressure,  and  pregnancy.  The 
effect  of  food  has  often  been  noticed,  the  urine  of  fasting  being  some- 
times natural,  or  at  least  clear  or  only  bloody,  while  that  passed  after 
food  is  milky.  In  the  case  of  Dr.  Bence  Jones's  patient,  the  urine  was 
most  chylous  after  dinner,  and  least  chylous  before  breakfast.  It  was 
more  frequently  chj^lous  after  animal  than  after  vegetable  food;  and  it 
was  oftener  free  from  chyle  before  breakfast  when  the  diet  was  vegetable 
than  Avhen  it  consisted  more  of  animal  food. 

My  patient  Eugenia  P passed  during  the  day  what  looked  like 

rich  milk  or  cream,  in  the  night  and  before  breakfast  urine  which  was 
less  opaque,  often  urinous  in  color  or  conspicuously  sanguineous.  Carter 
noted,  with  regard  to  one  of  his  Hindoo  patients,  that  ingestion  of  flesh 
or  wheaten  bread  increased  the  disease,  while  in  the  case  of  another,  if 
he  abstained  from  food  for  a  whole  day,  the  urine  ceased  to  be  chylous. 

One  case  has  been  recorded  as  exceptional,  in  which  "  the  urine  passed 
during  the  day  Avas  clear  and  free  from  chyle,  while  that  voided  during 
the  night  and  in  the  morning  was  deeply  loaded  with  it."'  It  may  be 
suggested  that  in  this  case  there  was  some  peculiarity  whereby  the  dis- 
charge was  alTected  by  jjosture,  as  sometimes  occurs. 

As  a  rule,  the  urinary  admixture  is  tlie  most  plentiful  when  the  pro- 
per chyle  channels  are  at  their  fullest,  and  on  the  other  hand  it  is  to  be 
observed  that  conditions  of  health  which  interfere  with  nutrition  are  apt 
to  cause  the  urine  to  revert  to  its  normal  state.  Thus,  in  Dr.  Prout's 
experience  the  urine  ceased  to  be  chylous  during  an  attack  of  hepatitis 
with  much  fever,  and  again  during  severe  mercurial  salivation.  The 
same  suspension  has  been  known  to  occur  upon  the  appearance  of  a 
carbuncle,*  during  inflammation  of  the  lungs,  and  on  the  approach  of 
death. 

The  disorder  is  influenced  also  by  movement,  as  a  rule  increased  by 

'  G.  C.  Dutt,  Lancet,  July,  1863,  p.  87. 

*  Elliotson's  case.     Med.  Times,  1857,  vol.  ii.  p.  287. 


CHYLURIA.  261 

exercise,  mitigated  by  repose,  though,  in  oue  of  Rayer's  cases,  riding  on 
horseback  was  thought  to  favor  the  return  of  the  urine  to  its  natural 
state;  it  is  affected  also  by  position.  An  instance  is  mentioned  in  which 
the  urine  ceased  to  be  chylous  when  the  patient  lay  on  his  right  side. 
A  tight  belt  round  the  belly  and  loins  was  found  by  Bence  Jones  to  have 
but  a  slight  restraining  influence  upon  the  discharge.  The  striking  re-, 
suits  in  this  respect  of  pressure  upon  the  front  of  the  lower  lumbar  verte- 
brje  is  related  in  another  paragraph. 

Among  the  conditions  which  influence  the  disease,  perhaps  pregnancy 
and  its  sequelre  are  those  which  boar  upon  it  in  the  most  striking  manner. 
The  disorder  often  begins  during  lactation,  or  returns  or  becomes  exag- 
gerated after  delivery.  With  Mr.  Pearse's  patient  the  chyluria  three 
times  appeared  during  lactation,  and  twice  subsided  on  its  discontinu- 
ance. Dr.  Roberts  saw  a  case  in"  which  the  disorder  came  on  imme- 
diately after  confinement.  Dr.  Lewis  mentions  one  in  which  it 
began  two  months  afterwards,  and  tinother  in  which  the  complaint  ap- 
peared in  the  third  month  of  pregnancy,  passed  off,  and  reappeared 
upon  the  birth  of  the  child.  S.uch  cases  cannot  fail  to  suggest  that  the 
channels  necessary  to  the  perversion  of  the  chyle  are  less  patent  when 
the  uterus  is  full  than  when  it  is  empty,  as  if  they  were  pressed  upon  by 
its  larger  bulk.  But  conditions  aft'ecting  in  other  ways  the  state  of  the 
pelvic  vessels  appear  sometimes  to  influence  the  disorder.  A  case '  is 
mentioned  in  which  the  urine  always  became  chylous  for  eight  days  pre- 
ceding menstruation;  and  another  in  which  the  chylosity  was  suspended 
for  three  years  on  the  establishment  of  a  hsemorrhoidal  flux.  Thus  it 
appears  to  be  promoted  by  turgidity,  relieved  by  evacuation. 

A  discharge  of  chyle  with  the  urine  is  in  a  certain  proportion  of  cases 
accompanied  by  a  similar  flux  from  the  surface  of  the  body,  usually  from 
the  lower  part  of  the  abdomen,  groin,  scrotum,  or  thigh.  Such  super- 
ficial discharges  are  apt  also  to  occur  where  chyluria  is  endemic  in  per- 
sons who  have  not  become  subject  to  it ;  circumstances  which  suggest 
that  the  superficial  and  urinary  discharges  are  common  results  of  the 
same  peculiarity  of  the  absorbents,  whatever  that  may  prove  to  be.  Dr. 
V.  Carter  has  related  several  cases  of  these  kinds,  and  shown  how  close 
is  the  resemblance  between  the  discharge  from  the  surface  and  the  ad- 
mixture with  tlie  urine. 

Dr.  Carter  describes  the  case  of  a  Hindoo,  the  skin  of  whose  scrotum 
was  peculiarly  corrugated  and  studded  with  small  tubercles  or  pimples, 
which  varied  in  size  from  a  pin's  head  to  a  pea,  and  opened  from  time  to 
time,  discharging  milky  fluid,  often  to  the  amount  of  a  pint  daily.  The 
inguinal  glands  on  both  sides  were  enlarged,  soft,  and  doughy,  and 
diminished  in  size  under  pressure.  The  urine  was  sometimes  chylous, 
this  condition  alternating  with  the  swelling  of  the  inguinal  glands, 
which  was  greatest  two  or  three  hours  after  a  full  meal.  The  fluid  that 
escaped  from  the  scrotum  Avas,  says  Dr.  Carter,  probably  chyle  or  a  mix- 
ture of  this  with  lymph.  AVhile  flowing  it  assumed  a  decided  rose  tint, 
which  increased  on  further  exposure.  It  coagulated  entirely  in  eight  or 
ten  minutes.  The  urine  also  coagulated  more  or  less  completely,  and 
assumed  after  some  exposure  a  pinkish  color.  The  microscopic  charac- 
ters of  the  two  fluids  were  almost  the  same;  chyle  corpuscles  were  recog- 
nized in  the  urine  ;  in  the  scrotal  discharge  corpuscles  like  those  of 
lymph,  together  with  the  molecular  base  characteristic  of  chyle.     The 

'  Referred  to  by  Roberts. 


262  CHYLURIA. 

blood  serum  was  quite  clear.  In  such  a  case  it  is  scarcely  possible  to 
doubt  that  the  same  chylous  fluid  escapes  both  into  the  urinary  channels 
and  also  by  way  of  the  inguinal  glands  to  the  skin  of  the  scrotum. 

Instances  have  also  been  recorded  in  which,  without  any  alteration 
of  urine,  milky,  apparently  chylous  fluid  has  been  discharged  superfi- 
cially from  the  lower  part  of  the  trunk  or  upper  part  of  the  thighi?. 
always,  it  would  seem,  from  some  surface  which  is  within  the  range  of 
regurgitation  from  the  lacteals  or  receptaculum,  supposing  valvular 
hindrance  to  be  overcome.  Pellucid  or  lymphous  discharges  have 
indeed  been  known  to  proceed  fi-om  the  upper  parts  of  the  body,  as 
from  the  eyelids,  and  Dr.  Lewis'  has  described  an  instance  in  which  this 
discharge  was  ""  slightly  milky;  "  under  the  microscope,  however,  it  dis- 
played "  clear  fluid  ^'' with  numerous  granular  cells;  the  molecular  base 
of  chyle  was  apparently  absent.  The  fluxes  which  have  the  characters 
of  chyle,  that  is  to  say,  are  milky  from  molecular  fat,  are  without  ex- 
ception within  the  anatomical  range  specified,  a  fact  which  is  suffi- 
ciently suggestive  that  in  these  cases,  as  in  those  of  chyluria,  we  have 
but  the  simple  retrogression  and  escape  of  chyle.  Such  an  instance  is 
related  by  Dr.  Y.  Carter.  A  Parsee  youth  had,  in  the  cutaneous  sur- 
face of  the  thigh,  a  few  inches  below  Poupart's  ligament,  a  small, 
hardly  perceptible  pimple,  from  which  there  occasionally  issued  a  milky 
fluid,  sometimes  so  copiously  that  in  the  course  of  a  day  a  pint  could  be 
collected.  Pressure  just  above  the  spot  caused  the  flow  to  cease;  when 
the  spot  itself  was  comi)ressed  the  fluid  squirted  out  as  if  from  accumu- 
lating pressure  behind.  The  inguinal  glands  were  enlarged,  soft,  and 
doughy.  The  fluid  resembled  rich  milk  in  appearance;  it  coagulated 
spontaneously,  it  was  uniformly  hazy,  under  the  microscope  contained 
blood  corpuscles,  granular  cells,  and  oil  globules — had,  in  short,  the 
character  of  a  ch3'lous  fluid.  Another  striking  instance  of  this  kind  is 
related  by  Dr.  A.  B.  Buchanan.^  A  woman  forty-six  years  of  age  had  a 
semi-excoriated  surface  as  large  as  the  j)alm  of  the  hand  upon  the  inner 
and  posterior  aspect  of  the  left  thigh.  From  this  and  from  broken  ves- 
icles upon  and  about  it  flowed  milky  fluid  so  jirofusely  that  five  ounces 
were  collected  in  an  hour.  The  fluid  was  often  absolutely  undistin- 
guishable  by  color  and  smell  from  pure  new  milk;  it  coagulated  through- 
out after  being  passed,  the  mass  breaking  down  on  agitation.  It  was 
albuminous;  under  the  microscope  it  displayed  cells  like  the  white  cor- 
puscles of  blood,  a  molecular  base  like  that  of  chyle,  and  a  few  fat 
corpuscles.  Chemical  analysis  showed  that  it  nearly  resembled  in  its 
composition  the  chylous  urine  examined  by  Dr.  Beale  (see  p.  25G),  ex- 
cept that  the  crural  discharge  contained  more  albumin  and  less  fat  than 
the  renal.  Dr.  Buchanan  repudiates  as  anatomically  impossible,  and 
pathologically  unnecessary,  "the  theory  that  in  such  a  case  the  dis- 
charge is  actual  chyle,  which  has  found  its  way  by  the  absorbents  to  the 
surface,  and  prefers  to  regard  the  flux  as  a  functional  affection  of  the 
glandular  a})})aratus  of  the  skin."  But  that  so  small  a  cutaneous  sur- 
face should  yield  so  profusely  and  so  long  as  the  result  of  any  change 
limited  to  itself  is  inconceivable;  and  if  the  skin  but  furnishes  the  exit 
— and  it  would  seem  that  it  can  scarcely  do  more — to  fluid  derived  from 
within,  tli9  characters  of  the  discliarge,  as  in  the  case  of  chylous  urine, 
assimilate  it  so  nearly  to  the  contents  of  the  lacteals  that  it  is  scarcely 

'  On  a  Hd'inatozoon  inhabiting  the  Human  Blood.     Calcutta,  1872,  p.  13. 
-  Med.-Chir.  Trans.  1863,  p.  57. 


CHYLURIA.  263 

possible  but  to  assign  its  origin  to  those  channels.  In  Dr.  Carter's  case 
there  was  no  altered  extent  of  skin,  but  merely  a  pimple  which  gave  exit 
to  the  discharge;  so  that  in  this  case,  at  least,  the  theory  of  cutaneous 
secretion  is  inapplicable. 

A  case  of  the  same  sort  came  under  the  observation  of  Dr.  Eoberts 
of  Manchester.  A  man  always  resident  in  Lancashire  had  a  succession 
of  subcutaneous  abscesses  in  various  parts,  among  others,  one  upon  the 
abdomen.  This  Avas  succeeded  by  an  extensive  vesicular  eruption  upon 
the  front  of  the  belly,  between  the  level  of  the  umbilicus  and  the  groin. 
Some  vesicles  were  scarcely  visible  to  the  naked  eye,  others  as  large  as 
peas;  all  were  at  times  filled  with  fluid  which  looked  like  rich  milk,  gel- 
atinized when  discharged,  contained  albumin,  and  displayed  under  the 
microscope  fat  molecules,  sometimes  distinct  oil  globules,  and  white 
corpuscles  like  those  of  blood.  This  exudation  varied  in  color  accord- 
ing to  the  state  of  digestion,  was  pale  or  lyraphous  with  fasting,  milky 
after  food.  The  vesicles  discharged  freely;  one  which  was  punctured  at 
the  rate  of  eight  ounces  an  hour.  Tlie  discharge  was  apparently  identi- 
cal with  that  which  forms  the  admixture  in  chylous  urine,  and,  indeed, 
on  two  occasions  chylous  urine  was  passed  by  this  patient.  He  died 
with  pulmonary  tuberculosis.  Nothing  abnormal  was  detected  about 
the  thoracic  duct  or  large  lymphatic  vessels.  The  affected  skin  was 
thickened  and  excavated  with  large  lacuna,  of  which  the  suj^erficial  ves- 
icles formed  the  orifices.  The  sweat  and  proper  cutaneous  glands  were 
not  involved  in  the  change,  which  Dr.  Eoberts  regards  as  the  develop- 
ment in  the  skin  of  an  abnormal  lymjjhatic  structure,  analogous  to  Pey- 
er's  patches  or  the  lymphatic  glands,  which  new  structure  is,  in  his  view, 
not  merely  the  outlet  but  the  source  of  the  discharge. 

The  pathology  of  cutaneous  "  chylorrhoea '*'  has  been  made  the  sub- 
ject of  further  inquiry  in  regard  to  a  case  published  by  Mr.  Sydney  Jones 
in  the  "  Pathological  Transactions  "  for  1875.  The  inner  and  back  part  of 
the  right  thigli  and  the  cleft  between  the  thigh  and  the  buttock  Avere  cov- 
ered with  knotty  swellings  and  varicose  lymphatics,  from  which  chyl- 
ous fluid  escaped  sometimes  to  the  amount  of  one  or  two  quarts  a  day. 
Similar  fluid  also  escaped  from  a  tuberculated  prominence  on  the  shin, 
and  the  skin  on  some  of  the  toes  was  tuberculated  as  in  elephantiasis. 
When  the  discharge  from  the  thigh  was  absent  the  inguinal  glands 
swelled.  Portions  of  the  affected  skin  were  removed  from  the  thigh  and 
one  of  the  toes  and  minutely  examined.  They  were  traversed  in  both 
instances  by  large  communicating  chambers  which  were  dilated  lym- 
phatics or  lymphatic  spaces.  These  were  lined  by  an  endothelium,  but 
appeared  to  be  destitute  of  any  proper  secreting  cells.  Veins  were  in 
close  apposition  to  their  walls,  and  in  some  instances  appeared  to  com- 
municate with  their  cavities.  No  filarijB  were  found  in  the  blood  or 
tissues,  but  the  superficial  dilatation  of  the  lymphatics,  together  with 
the  swelling  of  the  inguinal  glands  when  the  discharge  was  absent,  are 
enough  to  suggest  a  similar  state  of  the  deeper  and  larger  channels,  and 
the  probability  of  regurgitation  from  the  j^roper  chyle  vessels.  This 
case  affords  no  support  to  the  idea  of  a  local  chylous  secretion;  and  in- 
deed it  is  probable  that,  with  the  knowledge  which  has  now  been  gained, 
those  who  formerly  held  this  view  will  no  longer  maintain  it. 

As  touching  the  relationship  between  cutaneous  and  urinary  dis- 
charges of  clwle,  some  cases  reported  by  Dr.  Lewis  have  especial  inter- 
est. Dr.  Lewis  gives  examples  of  the  concurrence  of  chyluria  and  ele- 
phantiasis, and  relates  an  instance  of  the  latter  disorder  in  which  from 


264  CHYI.UKIA. 

the  scrotum,  which  was  the  part  affected,  exuded  by  minute  orifices 
a  chylous  fluid  in  which  living  filarice  were  detected.'  ^Ye  here  see  a 
superficial  chylous  discharge  associated,  not  indeed  with  chyluria,  but 
with  a  cause  of  chyluria.  The  evidence  adduced  by  Dr.  Lewis  suffices 
to  show  that  all  three  conditions,  a  discharge  of  chyle  both  by  the  skin 
and  with  the  urine  and  elephantiasis,  are  alike  associated  with  filarise. 
The  discharge  from  the  eyes  already  referred  to  was  also  found  by  Dr. 
Lewis  to  contain  these  parasites. 

The  Filaria. 

The  pathology  of  chyluria,  together  with  that  of  superficial  chj'lous 
discharges  and  of  elephantiasis,  has  been  reconstructed,  I  may  also  say 
created,  by  the  recent  discovery  of  the  filaria  sanguinis  hominis  and  the 
larger  worm,  also  a  denizen  of  the  human  body,  of  wiiich  the  filaria  is 
the  offspring.  The  accumulated  evidence  that  the  filaria  is  nearly 
always  to  be  found  in  the  blood  at  certain  times,  in  concurrence  with 
superficial  or  urinary  chylous  discharges  and  often  in  the  urine  when 
the  flux  occurs  with  this  secretion,  makes  it  necessary  to  preface  the 
morbid  anatomy  of  these  disorders  with  a  description  of  the  parasite. 
The  great  discovery  of  Lewis,  for  it  is  no  less,  and  the  observations 
which  have  been  added,  esi^ecially  by  Bancroft,  Manson,  and  Macken- 
zie, have  not  only  made  our  previous  knowledge  coherent  and  intelligi- 
ble, but  have  removed  the  pathology  of  chyluria  out  of  the  region  of 
speculation  and  guesswork  to  that  of  knowledge,  incomplete  as  yet  in 
some  of  its  details,  but  enough  to  give  the  assured  outlines  of  a  strik- 
ing and  even  astonishing  picture. 

It  had  long  been  known  that  dogs,  particularly  the  pariah  dogs  of 
India,  were  liable  to  be  infested  with  a  peculiar  round  worm,  to  which 
from  its  red  color  the  name  filaria  sanguinolenta  was  given,  which  lodged 
chiefly  in  the  walls  of  the  oesophagus  and  aorta,  and  discharged  its  ova 
according  to  circumstances  into  the  alimentary  canal  or  circulation. 
More  recently  another  similar  parasite,  to  which  the  name  Jilariainwiit is 
was  given,  was  ascertained  to  exist  chiefly  in  the  dogs  of  China,  taking 
its  residence  in  the  right  ventricle,  and  pouring  living  embryos  into  the 
blood.  The  parent  worms  in  both  these  cases  are  of  considerable  size, 
the  filaria  sanguinolenta  approaching  four  inches  in  length,  the  filaria 
immitis  exceeding  six.  The  embryos,  which  in  botli  cases  are  abundantly 
distributed  throughout  the  systemic  blood,  nearly  resemble  the  filaria 
sanguinis  hominis,  which  will  be  presently  described. 

The  minute  human  haematozoon,  whose  existence  as  such  was  made 
known  to  us  by  Dr.  Lewis  at  Calcutta  in  the  year  1872,  is  a  minute  ver- 
miform creature  about  forty-six  times  as  long  as  it  is  wide,  and  whose 
width  is  about  that  of  a  red  blood-corpuscle.  Its  structure  is  nearly 
simple,  granular  matter  within  a  hyaline  sheath,  with  a  point  at  each 
end  which  appears  and  disappears  with  movement,  one  passing  as  a  tail 
the  other  as  a  tooth.  Dr.  Lewis  found  six  of  these  in  a  single  drop  of 
blood  from  the  ear,  and  gave  700,000  as  an  approximation  to  the  number 
contained  in  the  whole  body.  This  estimate  has  been  very  greatly  ex- 
ceeded since  it  has  been  recognized  that  it  is  the  habit  of  the  parasite  to 
come  abroad  at  night.  Dr.  Mackenzie  calculated  that  a  jjaticnt  whose 
case  he  has  reported  had  nightly  from  thirty-six  to  forty  millions  of  em- 

'  The  Pilhological  Significance  of  Nematode  Hematozoa,  p.  46. 


CHYLUKIA. 


265 


bryo  filarifB  in  his  blood.  The  worms  show  much  vivacity  among  tlie 
corpuscles,  throwing  them  aside  by  their  active  serpentine  movements. 
It  was  at  once  conjectured  that  these  minute  creatures  were  the  young 
of  a  larger  worm,  and  the  surmise  was  verified  by  the  discovery  of  the 
parent  on  Dec.  21st,  1876,  by  Dr.  Bancroft  of  Brisbane.  The  mature 
form,  a  worm  of  the  nematode  class  about  the  thickness  of  a  human  hair 
and  three  or  four  inches  long,  was  first  found  in  a  lymphatic  abscess  of 
the  arm,  and  afterwards  in  hydrocele  fluid  obtained  from  patients  who 
were  known  to  be  infested  with  embryonic  filarise.     The  adult  was  mi- 


Filaria  sanguinis  hominis,  orBancrofti.  a,  female  (natural  size);  b,  head  and  neck  (X  55diam.> 
c.  tail;  d,  free  embryo  (X  400  diam.);  e,  egg  containing  an  embryo;  /,  egg  showing  the  yolk.  After 
CobboU) . 

nutely  described  by  Dr.  Cobbold,  from  specimens  sent  by  Dr.  Bancroft, 
and  named  filaria  JBancrofti,  different  names  being  thus  awarded  to  dif- 
ferent stages  of  the  same  parasite.  Tlie  annexed  figure  is  copied  from 
Dr.  Cobbold's  description.'  I  have  added  anotlier  from  a  photograph 
published  by  Dr.  Stephen  Mackenzie,  which  enables  the  immature  off- 

'  Parasites,  1879,  p.  188.  "  Discovery  of  the  Adult  Representative  of  Micro- 
scopic FilariiB."     Dr.  Cobbold.     Lancet,  July  14th,  18T7,  p.  70. 


■266 


CHYLURIA. 


spring  as  it  is  found  in  the  blood  to  be  compared  in  size  with  the  corpus- 
cles. Dr.  Lewis  himself  found  the  parent  worm  at  Calcutta  on  tlie  5tli 
of  the  following  August,  in  a  scrotum  infiltrated  with  chylous  fluid  in 
connection  with  elephantoid  disease. '  Two  white  threads  were  found  in 
a  blood-clot,  which  proved  to  be  male  and  female  specimens  of  the  adult 
filaria.  The  female  contained  ova  witli  embryos  identical  with  those 
which  Dr.  Lewis  had  already  found  in  the  blood.  The  occurrence  of 
these  creatures  in  pairs  in  tlie  remote  recesses  of  the  human  body  shows 
the  efficacy  of  the  sexual  instinct,  in  virtue  of  which  one  worm  follows 
and  eventually  finds  anotlier  witliin  a  maze  to  which  that  of  Fair  Eosa- 
mond  was  comparatively  uninvolved.  Dr.  Manson '  has  recently  demon- 
strated the  position  of  the  parents  in  a  dilated  lymphatic  belonging  to  a 
h/mph-scrotttui  which  he  had  recently  amputated.  The  creature  is 
viviparous,  normally  discharging  its  ott'spring  extended  and  free  ;  mis- 
carriage, however,  appears  to  be  a  frequent  accident,  in  Avhich  case  the 
ova  are  discharged  unhatched,  with  the  worm  curled  up  within,  thus 
presenting  a  larger  bulk  than  when  the  process  is  more  happily  con- 


Filaria  in  human  blood.    After  photograph  pubhshed  by  Dr.  Mackenzie. 


ducted,  and  producing  pathological  consequences  which  will  be  presently 
adverted  to. 

Many  valuable  observations  have  since  been  added  throwing  light 
upon  the  habits  of  the  j^arasite,  its  means  of  transmission,  and  its  rela- 
tions to  disease.^  Dr.  Manson,  in  China,  in  the  year  1877,  provided 
the  next  step  by  a  discovery  not  inferior  in  interest  to  any  that  had  been 
already  made.  Believing  that  the  asexual  embryo  did  not  attain  matu- 
rity in  the  place  of  its  birth,  but  required,  after  the  manner  of  parasites, 
to  be  transferred  to  another  animal  for  further  development,  he  sought 
for  the  nurse  among  the  insects  that  feed  on  blood,  and  found  it  in  the 


By  Dr.  Lewis.     Lancet,  Sep- 
'     Cobbold.     Lancet,  October 


'  "  Filaria  Sanguinis  Hominis"  (mature  form), 
tember  29th,  1S77,  p.  453.  "  On  Filaria  Bancrofti. 
6th,  1877,  11.  49"). 

'■'  Path.  Trans.,  vol.  xxxii.  p.  285. 

2  Dr.  Manson.  ''On  the  Filaria  Disease  at  Amoy."  Customs  Med.  Reports, 
China,  1877.  "  Lymph-Scrotum,  showing  Filaria  in  situ."  Dr.  Manson,  Pa</i. 
Trans.,  vol.  xxxii.  p.  285. 


CHYLURIA.  267 

mosquito.  Dr.  Manson,  suspecting  this  insect,  induced  a  Chinaman 
who  was  infested  with  filariae  to  sleep  in  a  house  where  mosquitoes  were 
wont  to  congregate.  A  number  of  these,  which  had  been  attracted  by 
means  of  a  light,  were  shut  up  with  the  man,  and  in  the  morning  found 
upon  the  walls  in  a  state  of  repletion.  Filariae  Avere  abundantly  found 
in  their  distended  stomachs,  and  Dr.  Manson  ascertained  by  numerous 
observations  that  upon  entering  the  mosquito  the  more  fortunate  of  the 
filariae  began  a  process  of  development  which,  in  from  four  to  six  days, 
transformed  each  into  a  somewhat  complicated  animal,  with  an  cesopha- 
gus,  rudimentary  generative  organs,  and  papillre  upon  its  head,  perhaps 
for  boring  or  attachment.  The  filariae  are  said  to  be  found  in  the  blood 
in  the  mosquito's  stomach  in  larger  proportion  than  in  that  of  the  man 
from  which  it  has  been  taken,  as  if  the  parasites  were  especially  attracted 
by  the  insect.  The  mosquito,  of  which  only  the  female  is  capable  of  thus 
abstracting  blood,  retires,  when  replete,  to  the  neighborhood  of  water, 
to  digest  its  meal  and  mature  its  ova.  At  the  end  of  about  five  di\ys 
both  processes  are  complete  ;  the  blood,  and  possibly  many  of  the  fila- 
riae, are  digested,  but  the  survivors,  still  within  the  mosquito,  have 
become  transmuted  into  the  formidable  parat'ite  which  Dr.  Manson  has 
described.  The  insect  now  dies,  probably  falling  into  the  water,  upon 
which  she  has  already  laid  her  eggs,  and  the  now  vigorous  filarife,  if  the)' 
have  not  already  escaped  with  the  ova,  either  bore  their  way  out  of  the 
mosquito,  or  fall  out  upon  its  decay,  to  enter  the  water  and  probably  be 
swallowed  by  the  animal  which  is  destined  to  become  the  seat  of  its  fur- 
ther growth  and  completion.  The  details  of  this,  the  last  stage  of  its 
career  have  not  been  followed,  but  there  is  little  doubt  that  the  creature 
makes  its  way  by  boring  into  a  suitable  lymphatic  channel,  and  there 
completes  its  growth  into  the  tangible  worm  which  has  been  already  de- 
scribed ;  is  there,  by  good  hap,  joined  by  one  of  the  opposite  sex,  and 
the  species  continued  by  the  pouring  of  the  embryonic  filariae  into  the 
lymphatic  channels,  from  whence  they  reach  the  blood  and  the  mosquito. 

The  embryo  filaria  is,  as  Dr.  Manson  pointed  out,  of  nocturnal 
habits;  abundantly  to  be  found  in  the  blood  during  the  night;  not  to  be 
found  during  the  day.  He  found  them  to  present  tliemselves  at  about 
7  o'clock  in  the  evening,  to  increase  up  to  midnight,  and  to  have  dis- 
appeared by  8  or  9  in  the  morning.  Dr.  Mackenzie  '  added  the  observa- 
tion that  this  periodicity  depended  upon  sleep:  on  reversing  the  hours  of 
sleeping  and  waking  in  a  case  under  his  observation,  the  filarire  changed 
their  course  of  proceeding,  coming  out  while  the  patient  slept,  and  re- 
maining hidden  during  his  waking  hours.  What  becomes  of  the  filariae, 
or  where  they  retreat  to  during  their  disappearance,  we  have  no  evidence 
to  show. 

These  parasites,  which  obstruct  the  lymphatics  and  teem  in  the  blood, 
do,  on  the  whole,  less  harm  than  might  have  been  expected.  The  em- 
bryos appear  to  pass  through  the  capillaries  without  difficulty,  and  to 
have  no  tendency  to  cause  obstruction.  It  might  be  supposed  that  each 
filaria  would  become  a  centre  of  coagulation  and  an  embolus;  but  the 
blood  appears  to  be  as  tolerant  of  the  animal  as  of  its  own  corpuscles, 
and  to  alloAV  it  as  free  passage  through  its  smallest  channels.  But  it  is 
not  so  with  the  ova,  which  have  been  seen  unhatched  in  the  lymphatics, 
in  the  blood,  and  in  the  urine,  as  the  result,  probably,  of  accident  or 
abortion;  these,  as  Dr.  Manson  has  shown,  present  at  least  five  times  the 

'  Path.  Trans.,  vol.  xxxiii.  p.  401. 


268  CHYLURIA. 

diameter  of  the  outstretched  filaria,  and,  though  passing  easily  along  the 
larger  lymphatics  into  whicli  they  are  borne,  are  arrested  in  the  smaller 
channels  of  the  first  lymphatic  gland  the\'  reach.  Here  they  become 
imjjacted,  and,  as  the  process  goes  on,  accumulate  in  sufficient  numbers 
to  make  the  gland  impervious,  and  give  rise  to  the  localized  lymphatic 
congestion  which  is  the  essential  fact  of  elephantiasis,  lymph-scrotum, 
and  similar  conditions.  As  tlie  result  of  obstruction  by  such  means  of 
lympliatic  glands,  we  may  have  a  series  of  affections  which  are  limited  to 
the  tributaries  of  the  gland  concerned,  and  are  often  su])erficial.  But 
other  affections  may  ensue  from  the  occlusion,  by  the  parent  worms,  of 
the  larger  lymph  and  chyle  channels.  These  have  been  demonstrated, 
as  already  stated,  in  a  scrotal  vessel,  and  there  can  be  no  doubt  that  the 
deeper  channels,  among  others  the  thoracic  duct,  are  liable  to  be  simi- 
larly stopped. 

Eecent  as  our  knowledge  of  the  filaria  is,  we  have  already  been  pro- 
vided with  extensive  information  as  to  its  pathological  effects  and  the 
absence  of  them.  Dr.  Manson  found,  as  the  result  of  systematic  search, 
that  of  every  ten  Chinamen  at  Amoy,  taken  at  random,  the  blood  of  one 
contained  filariae.  But  many  of  those  were  apparently  in  perfect  health. 
Of  195  persons  in  this  condition,  ten  were  found  on  examination  to  be 
filarious,  so  that  to  harbor  this  parasite  is  not  necessarily  injurious. 

But  we  have  evidence  from  Lewis,  Bancroft,  Manson,  and  others,  of  a 
large  variety  of  disorders  which  occur  together  with  this  parasite,  and 
are  presumably  caused  by  it.  A  large  i:)roportion  of  these  are  of  the 
elephantoid  type,  elephantiasis  especially  of  the  scrotum,  what  is  known 
as  lymph-scrotum,  and  enlarged  and  varicose  inguinal  glands.  Dr. 
Manson  found  that  of  sixty-three  persons  with  one  or  other  of  these  affec- 
tions, thirty-six  were  filarious.  Passing  attacks  of  fever,  known  as  ele- 
phantoid. a]3pear  to  be  of  frequent  occurrence.  Hydrocele,  orchitis,  in- 
flammation of  the  scrotum,  and  a  number  of  superficial  affections  of  the 
lympliatic  system,  have  been  recorded  in  the  same  relation — cutaneous 
lymph-vesicles,  chylous  and  lymphous  discharges,  a  disorder  of  this 
class  known  in  Brazil  as  crow-crow,  and  a  peculiar  form  of  facial  steatoma. 
Besides  results  of  obstruction,  superficial  abscesses,  presumably  due  to 
the  death  of  the  parent  worm,  have  been  repeatedly  observed,  as  also 
have  attacks  of  diarrhoea  and  dysentery.  As  the  only  morbid  result  due 
to  the  embryo  in  the  blood.  Dr.  Manson  mentions  ulceration  of  the 
cornea. ' 

Filarije  have  been  found  with  leprosy;  *  it  is  yet  too  early  to  say  whether 
the  concurrence  is  accidental  or  necessary.  The  list  may  be  closed  with 
chyluria,  which,  whether  associated  with  some  elephantoid  affection  or 
occurring  alone,  is  one  of  the  most  important,  and  in  some  districts  one 
of  the  most  frequent  of  the  consequences  of  the  parasite.  Dr.  Manson 
at  Amoy  found  elephantiasis  far  more  frequent  than  chyluria.  Dr. 
Bancroft  at  Brisbane  found  chyluria  more  frequent  than  any  superficial 
localization  of  the  disease,  though  not  so  frequent  as  all  of  them  together. 
Among  thirty-one  cases  of  disease,  presumably  of  filarious  origin.  Dr. 
Bancroft  found  chyluria  in  eleven  instances;  some  superficial  affection, 
probably  of  the  same  origin,  in  twenty. 


'  Further  Observcttions  on  the  Filaria  Sanguinis  Hominis,  p. 
*  Dr.  Bancroft.     Lancet,  Feb.  1st,  18:^2,  p.  175. 


CHYLURIA.  269 

MOKBIl)    Ax  ATOMY    AXD    PATHOLOGY    OF    ChYLURIA. 

Passing  from  the  filaria  in  general  to  its  particular  result  chyluria,  I 
may  briefly  state  what  is  known  with  regard  to  the  morbid  anatomy  of 
that  condition,  together  with  that  of  superficial  chylous  discharges. 
There  is  still  room  for  conjecture  in  som.e  details,  though  enough  has 
been  ascertained  to  place  our  knowledge  of  both  ujion  a  simple  mechani- 
cal basis. 

With  regard  to  chyluria  we  are,  to  begin  with,  indebted  to  Prout," 
who  examined  the  kidney  of  a  girl  who  had  died  with  chylous  urine  at 
the  age  of  fifteen,  and  found  it  to  be  perfectly  healthy — the  immediate 
cause  of  death  was  inflammation  of  the  bowels.  Not  to  refer  to  equivocal 
instances,  the  next  is  related  by  Dr.  Priestly.  The  subject  Avas  a  boy 
twelve  years  of  age,  who  had  passed  the  greater  part  of  his  life  in  the 
Mauritius  and  Ceylon.  Some  days  before  death  the  urine  had  lost  its 
chylous  character,  this  being  coincident  with  a  rapid  change  for  the  worse, 
the  patient  sinking  by  asthenia.  Both  kidneys  were  extensively  diseased, 
the  distinction  between  the  cortical  and  tubular  portions  was  lost,  and 
the  vascular  network  on  the  surface  of  the  healthy  organ  obliterated. 
The  microscope  showed  the  whole  structure  to  be  fatty,  as  in  some  of 
the  advanced  forms  of  Bright's  disease.  The  liver  Avas  loaded  with  fat, 
and  the  muscular  fibres  of  the  heart  had  lost  their  transverse  striae  and 
were  replaced  by  oil  globules.^  There  was  also  tubercular  disease  in  the 
apex  of  one  lung.  For  a  third  post-mortem  we  are  indebted  to  Dr. 
Isaacs.^  The  case  what  that  of  a  Spanish  soilor  who  had  had  the  dis- 
order at  irregular  intervals  for  three  years.  Both  lungs  were  studded 
equally  and  throughout  with  miliary  tubercles,  from  the  size  of  a  grain 
of  sand  to  that  of  a  mustard  or  hemp  seed.  Under  the  costal  pleura  they 
were  also  in  countless  numbers.  All  the  other  organs  were  healthy,  with 
the  exception  of  small  deposits  of  yellow  tubercular  matter  in  the  in- 
terior of  the  mesenteric  glands.  In  the  substance  of  the  prostate  were 
three  tubercles  about  the  size  of  buck-shot.  "  The  structure  of  the  kidney 
was  decidedly  healthy — the  only  morbid  appearance  was  the  presence  of 
a  very  few  small  and  scattered  tubercles,  which  did  not  apparently  inter- 
fere with  its  functions." 

I  have  already  referred  to  a  case  in  the  experience  of  Dr.  Roberts,  in 
which  a  chylous  discharge  issued  from  the  skin  of  the  abdomen.  Chy- 
lous urine  was  passed  on  two  occasions;  but  as  death  did  not  occur  until 
more  than  three  months  afterwards,  little  is, to  be  inferred  from  the 
state  of  the  urinary  organs.  The  bladder,  whicl)  was  minutely  examined, 
and  the  kidney,  were  healthy.  "  No  enlargement  or  unnatural  condi- 
tion of  the  thoracic  duct  or  of  the  lymphatic  vessels  or  glands  could  be 
detected."     The  condition  of  the  skin  has  been  already  referred  to. 

Dr.  Lewis  records  the  post-mortem  appearances  in  the  case  of  a  Eu- 
ropean woman  who  had  died  in  India  with  chyluria,  which  she  had  had 
Avith  intermissions  for  sixteen  years.  lisematozoa  had  been  found  nu- 
merously in  the  blood  and  in  the  urine.*  The  immediate  cause  of  death 
appeared  to  have  been  tuberculosis;  tubercle  and  vomica  Avere  found  in  both 
lungs,  and  there  were  ulcers  of  the  same  character  in  both  the  small  and 

'  Edit.  iv.  p.  119. 
"  Edin.  Med.  Journ.,  1856,  p.  945. 
^  Amer.  Journ.  of  Med.  Science,  1860. 

*  Lewis,  On  a  Hoematozoon  inhabiting  the  Human  Blood.  1872.  Pp.  17  and 
33. 


270  CHYLURIA. 

large  bowel.  The  liver  was  soft  and  fatty.  "  The  kidnej's  presented 
nothing  abnormal  to  the  naked  eye.''  A  further  examination  showed 
that  several  of  the  pyramids,  especially  near  the  apices,  had  a  smooth, 
tallowy  appearance,  suggestive  of  lardaceous  disease.  No  iodine  reac- 
tion could  be  obtained  either  upon  the  kidney  or  liver.  "When  longi- 
tudinal sections  of  the  kidney  were  subjected  to  microscopic  examina- 
tion, numerous  translucent,  oil-like  tubules,  of  a  somewhat  varicose 
appearance,  could  be  observed  running  alongside  the  uriniferous  tul)es, 
as  if  the  lymphatic  or  minute  blood-vessels  of  the  part  had  become 
plugged.  These  sections,  when  placed  in  boiling  ether,  and  afterwards 
subjected  to  prolonged  maceration  in  it,  did  not  appear  to  be  materially 
affected  by  the  process — the  translucent  oil-like  tubules  being  quite  as 
evident  as  before.  No  other  morbid  changes  could  be  detected  in  either 
the  tubular  or  cortical  tissue  of  the  kidneys,  but  in  every  fragment, 
no  matter  from  what  part  of  the  kidney  removed,  numerous  microscopic 
filariffi  were  invariably  obtained.  On  slitting  open  any  portion  of  the 
renal  artery,  from  its  entrance  into  the  kidney  as  far  inwards  as  I  was 
able  to  follow  its  ramifications,  and  scraping  the  inner  surface,  numerous 
hfematozoa  could  always  be  obtained.  The  renal  vein  when  similai;ly 
examined  also  yielded  specimens  of  the  filariae,  but  they  did  not  seem  to 
be  so  numerous  in  it.  The  vessels  themselves  did  not  appear  to  be  dis- 
eased.'*' It  is  to  be  added  that  the  same  parasites  were  also  found  in  the 
supra-renal  capsules.  The  condition  of  the  bladder  and  urinary  pas- 
sages is  not  mentioned. 

To  proceed  to  the  pathological  significance  of  the  facts,  it  is  in  the 
first  place  certain  that  the  admixture  with  the  urine  is  obtained  directly 
from  the  chyle  channels,  and  not  eliminated  from  the  blood-vessels.  The 
identity  of  the  urinary  addition,  both  in  substance  and  shape,  with  the 
contents  of  the  further  lacteals  and  thoracic  duct,  is,  as  has  been  already 
shown,  sutficient  warrant  for  the  presumption  that  the  urinary  organs 
import  rather  than  manufacture  the  constituents  which  are  foreign  to 
their  secretion.  As  to  the  route  by  which  the  chyle  reaches  the  urinary 
cavities,  we  may  at  once  i)ut  aside  the  secreting  structure  of  the  kid- 
neys as  not  involved  in  the  covirse.  If  the  sensitive  renal  tubes  were  for 
long  traversed  by  a  material  so  novel  to  their  habit  and  purpose,  it  might 
be  taken  as  certain  that  obvious  changes  in  the  gland,  probably  of  an 
inflammatory  kind,  would  ensue;  but  this  does  not  occur — after  years  of 
the  disorder,  the  kidneys  have  been  found  to  jiresent  to  a  critical  eye 
no  departure  from  the  natural  state.  In  Dr.  Priestly's  case,  where  the 
kidneys  were  fatty,  this  change  was  shared  by  other  organs,  and  may 
probably  have  been  connected  with  the  tubercular  disease  which  was 
present.  The  necessary  properties  of  the  urine  do  not  appear  to  be  im- 
paired by  the  disease,  neither  do  ura^nic  or  proper  renal  symptoms  ever 
result.  Again,  though  chylous  urine  is  often  so  fibrinous  as  to  coagulate 
within  the  body,  yet  casts^^  of  the  remil  tubes  are  not  found  in  it.  It 
would  seem  that  they  could  not  fail  to  be  formed  did  the  fibrinous  mix- 
ture traverse  the  ducts,  so  readily  in  almost  all  circiimstances  of  renal  dis- 
ease does  fibrin  solidify  in  these  narrow  and  tortuous  channels.  Pre- 
suming, therefore,  that  the  chylous  matter  is  not  a  renal  discharge,  it 
can  only  be  attributed  to  scrme  part  of  the  urinary  mucous  membrane. 
Taking  this  together  with  the  cutaneous  manifestations  of  what  may  be 
termed  chylorrhoea,  the  occasional  association  in  the  same  person  of  both 
the  urinary  and  the  cutaneous  form,  and  the  limitation  of  the  cutaneous 
variety  to  the  parts  of  the  body  the  absorbents  of  which,  like  those  of 


CHYLDRIA,  271 

the  bladder,  run  by  a  short  and  nearly  direct  course  into  the  lower  end 
of  the  thoracic  duct,  it  is  not  possible  to  doubt  that,  whether  affecting 
the  skin  or  mucous  membrane,  the  disorder  is  essentially  the  same,  con- 
sisting in  each  case  of  a  regurgitation  of  actual  chyle  from  its  proper 
Tessels.  The  chyle  after  reaching  the  lower  part  of  the  thoracic  duct  by 
the  lacteals,  instead  of  pursuing  its  upward  course  is  turned  backwards 
along  tlie  lymphatics,  which  proceed  res2)ectively  to  the  urinary  mucous 
membrane  and  the  adjacent  skin. 

The  absorbents  from  the  pelvis,  lower  limbs,  and  neighboring  parts 
enter  the  thoracic  duct  at  its  lower  part,  close  to  the  point  where  the 
contents  of  the  lacteals  are  received  ;  should  the  chyle  meet  with  any 
obstruction  in  its  upward  flow,  it  is  into  these  that  it  would  be  diverted, 
supposing  their  valvular  arrangement  should  prove  insufficient  to  prevent 
a  retrograde  current  within  them.  The  lymphatics  of  the  bladder  and 
of  the  parts  adjacent  to  the  groin  are  of  great  size,  and  are  comparatively 
short,  so  that  a  regurgitating  current  would  soon  reach  their  extremi- 
ties. A  backward  stream  from  the  receptaculum  would  pass  first  into 
the  absorbents  which  accompany  the  iliac  arteries  ;  thence  numerous 
and  wide  channels  lead  to  the  bladder,  while  others  enter  the  inguinal 
glands  to  pass  downwards  to  the  thigh  and  upwards  over  the  abdomen. 
The  pelves  of  the  kidneys  and  the  urethra  are  also  in  close  communica- 
tion with  the  thoracic  duct,  and  within  easy  reach  of  regurgitation.  It 
must  be  allowed  that,  notwithstanding  the  valuable  dissection  which  we 
owe  to  Dr.  Stephen  Mackenzie,  we  are  still  in  doubt  as  to  the  exact  part 
of  the  urinary  mucous  membrane  upon  which  the  chyle  is  discharged. 
The  constant  occurrence  in  chylous  urine,  as  I  have  already  pointed  out, 
of  large  globular  cells  sucli  as  belong  to  the  bladder,  would  suggest  that 
its  wall  is  the  place  of  the  leak.  At  the  same  time  it  must  be  allowed 
that  there  is  usually,  though  not  always,  complete  absence  of  vesical 
irritation,  while  if  there  be  pain  with  chyluria  it  is  usually  in  the  lumbar 
region.  We  must,  therefore,  regard  the  place  of  the  discharge  of  chyle 
as  still  uncertain.     It  may  not  always  be  the  same. 

As  to  the  hindrance  which  the  valves  of  the  lymphatics  present  to 
the  retrograde  current,  it  is  evident  that  a  certain  amount  of  dilatation 
is  all  that  is  needed  to  make  them  inefficient. 

It  is  possible  that  there  may  l)e  more  than  one  cause  which  leads  to 
the  regurgitation.  Any  obstruction  in  the  thoracic  duct,  whether  by 
parasites  or  otherwise,  would  conceivably  cause  it ;  but  we  are  justified 
in  putting  aside  other  causes  of  stoppage  as  at  least  exceedingly  infre- 
quent. Knowing  as  we  now  do  that  an  arrest  in  the  lymphatic  system 
leads  to  regurgitation  and  discharge,  we  can  but  infer  from  the  absence 
of  such  results  that  the  thoracic  duct  has  a  power  of  evading  aneurisms 
and  growths  Avhich  is  not  possessed  by  either  veins  or  arteries.  The 
mere  circulation  of  embryo  filariae  does  not  appear  to  be  })roductive  of 
chyluria,  or  indeed  of  any  other  prominent  symptom  ;  this  flux  can  be 
due  only  to  obstruction  in  the  thoracic  duct,  or  large  channels  between 
it  and  the  urinary  organs.  The  completion  by  Bancroft  of  the  discov- 
ery of  Lewis,  and  the  location  of  the  parent  worms  in  the  large  absorbent 
vessels,  supplies  the  mechanical  hindrance  and  occasions  the  regurgita- 
tion to  which  the  symptoms  are  duo.  The  constant  admixture  of  blood 
with  chylous  urine  is  presumably  to  be  explained  in  this  view.  Injury 
to  the  thoracic  duct  may  easily  be  sujiposed  to  affect  its  valvular  en- 
trance into  the  subclavian  vein,  so  that  not  only  chyle  but  blood  may 
regurgitate.     The  blood  in  such  iirine  might  possibly  proceed  from  the 


272  CllYLURIA. 

coats  of  the  bladder;  but  it  could  scarcely  be  derived  from  the  secreting 
structure  of  the  kidney  without  such  injury  to  the  gland  as  our  obser- 
vations, scanty  though  they  are,  are  sufficient  to  show  does  not  exist. 
If  the  hffiniatozoa  were  to  escape  from  the  blood-vessels  into  the  tissue, 
so  as  to  open  connection  between  channels  not  normally  communicating, 
it  is  impossible  but  that  inflammation  would  accrue,  probably  in  the 
form  of  diffuse  suppuration. 

With  regard  to  the  minority  of  ca^es  of  chyluria  which  originate  in 
Great  Britain,  it  is  to  be  borne  in  mind  that  the  mosquito  occasionally 
visits  our  shores,  and  it  is  possible  that  tlie  filaria  nuiy  be  introduced  as 
in  countries  where  this  insect  is  more  abundant.  It  is  also  possible  that 
there  may  exist  other  causes  of  lymphatic  obstruction  which  have  not 
yet  been  identified. 

Treatment. 

As  to  the  radical  cure  of  clnduria  by  the  destruction  of  the  jtarasite, 
we  know  of  no  drugs  which  are  effective  in  this  respect.  The  thoracic 
duct  is  in  more  immediate  reach  of  absorption  by  the  stomach  than  are 
the  systemic  blood-vessels,  though  scarcely  nearer  than  the  portal;  but 
it  is  not  consistent  with  our  experience  of  the  Bilharzia  that  an  animal 
in  the  latter  situation  should  succumb  to  anything  which  the  tissues  can 
endure;  and  it  is  not  to  be  expected  that  the  filaria  Avill  prove  more 
vulnerable.  Without  looking  for  specifics  we  must  be  content  to  seek 
measures  of  relief,  much  encouraged  by  the  consideration  that  if  we  can 
only  maintain  the  patient  against  the  disease  for  a  time,  it  will  often, 
with  apparent  caprice,  terminate  or  become  suspended. 

Considering  that  the  disease  does  harm  chiefly  by  the  diversion  and 
loss  of  the  nutritive  fluid,  it  is  obvious  that  it  may  be  of  service  to  prevent 
this  even  temporarily.  I  have  made  use  of  pressure,  directed  as  nearly  as 
might  be  made  upon  the  lymphatics  between  the  bladder  and  the  tho- 
racic duct,  in  the  hope  of  arresting  the  regurgitating  current.  Passing 
as  these  vessels  mainly  do  with  the  internal  iliac  arteries,  and  thence  by 
the  lumbar  glands,  it  would  seem  that  the  front  of  the  lower  lumbar 
vertebroe  affords  the  only  position  at  which  pi'essure  from  without  could 
be  effectively  brought  to  bear  upon  them. 

Dr.  Bence  Jones  was  led  to  the  belief  that  compression  of  the  kidney 
might  be  serviceable,  and  to  tliis  end  i;sed  in  one  instance  a  tight  belt 
around  the  loins,  but  the  results  were  insignificant.  The  enlarging 
uterus  appears  to  exert  the  necessary  pressure  more  effectively.  The  re- 
lation of  the  disorder  to  pregnancy  is  indeed  of  interest  in  several 
respects.  The  favorite  time  for  its  accession  or  return  appears  to  be  the 
period  of  lactation  ;  during  pregnancy  we  hear  little  of  it ;  in  an  in- 
stance mentioned  by  Dr.  Lewis,'  the  disoi'der  began  in  the  third  month, 
passed  off  five  or  six  weeks  later,  and  returned  after  delivery.  The  sus- 
pension of  the  complaint  corresponds  with  the  presence  of  the  uterus 
in  the  abdominal  cavity,  while  the  peculiar  liability  of  the  period  of 
lactation  to  its  attacks  may  be  connected  with  the  abnormal  relaxation 
of  tissue  which  follows  the  emptying  of  the  uterus  and  the  continuance 
of  lactation. 

Putting  aside  local  measures,  the  indications  are  two:  to  constringe, 
and  to  compensate.  With  regard  to  the  first,  Bence  Jones  thought  that 
the  discharge  was  controlled  by  gallic  acid,  given  in  the  amount  of  60 

'  On  a  Hcematozoon  inhabiting  Human  Blood.     1873.     P.  9. 


CHYLURIA.  273 

grains  a  day;  and  other  observers  have  attributed  good  results  to  the 
astringent  salts  of  iron.  How  far  the  discharge  is  under  the  control  of 
astringents  of  this  sort  may  be  doubted.  There  can  be  no  doubt  as  to 
the  importance  of  compensation  by  diet  and  nutritious  drugs.  The 
constitutional  symptoms  of  the  disease,  so  long  as  it  remain  uncompli- 
cated with  tubercle,  are  simply  those  of  inanition.  The  discharge  in- 
volves the  loss  both  of  the  fatty  and  of  the  nitrogenous  elements  of  food, 
so  that  the  diet  must  be  liberally  adjusted  in  all  respects.  Cod-liver  oil 
and  iron  were  obviously  indicated  by  the  wasting  and  pallor  of  my  own 
patient,  and  were  given  with  the  best  results.  Mangrove  bark  has  been 
recommended  as  an  empirical  remedy,  but  we  must  have  more  evidence 
than  has  yet  been  adduced  before  we  attribute  any  decided  benefits  to  its 
use. 

18 


OHAPTEE   XX. 
INTERMITTENT     IL^MATURIA     OR     H.EMO-GLOBINURIA. 

The  disorder  originally  described  as  intermittent  lijematuria  has  of 
late  become  possesssed  of  additional  titles.  Sir  William  Gull  proposed 
to  substitute  the  term  licBinatiniiria  for  that  previously  in  use  in  asser- 
tion that  hffimatin  rather  than  blood  in  its  entirety  was  introduced 
into  the  urine.  It  has  since  been  shown,  however,  that  the  character- 
istic discharge  is  hfemoglobiu  rather  than  htematin,  and  the  name  cor- 
respondingly changed  to  hgemoglobinuria,  the  term  now  in  most  frequent 
use.  It  is  clear,  however,  that  most  if  not  all  the  constituents  of  Ijlood, 
whether  in  shape  or  in  substance,  are  discharged  by  the  kidneys  in  this 
disease.  Fibrin  and  albumen  are  certainly  present,  the  former  both 
in  casts  and  otherwise;  and  albumin  is  to  be  detected  independently  of 
the  corpuscular  products  and  after  they  have  ceased  to  appear.  Perhaps, 
therefore,  we  may  remain  content  with  the  oldest  substantive  by  Avhich 
the  haemorrhage  has  been  designated.  Dr.  Pavy  has  sought  to  replace  the 
adjective  Intermittent  by  Paroxysmal  as  better  suited  to  describe  the  ■ 
irregular  recurrence  of  the  attacks,  and  more  recently  tterms  have  been, 
introduced,  as  Winter  Hsematuria,  Haemoglobinuria  a  Frigore,  or  From 
Cold,  in  assertion  of  the  general  exciting  cause  of  the  attacks.  But  in 
both  respects  I  prefer  the  original  distinction.  Intermission  does  not 
necessarily  imply  periodicity;  a  disorder  may  intermit  irregularly  and  in 
obedience  to  external  circumstances;  ague  itself  ma}'  return  capriciously, 
not  according  to  date  but  according  to  weather;  and  using  tlie  term  in- 
termittent thus  widely,  it  Avould  seem  to  be  especially  suited  to  the  dis- 
order in  question,  since  it  is  to  be  distinctly  reckoned  among  the  results 
of  the  marsh  poison.  The  terms  which  refer  to  cold  as  the  cause  of  the 
fits  are  descriptive  of  one  character  of  the  disease,  but  the  older  qualifi- 
cation has  also  a  special  apj^ropriateness  which  cannot  Avith  advantage 
be  lost  sight  of. 

The  disorder  is  one  of  remarkably  definite  characters.  The  patient, 
one  frequently  who  has  had  ague  or  been  exposed  to  malaria,  is  attacked 
sometimes  periodically,  but  more  often  after  chance  exposure  to  cold, 
with  rigors  like  those  of  ague,  speedily  followed  by  the  passing  of  urine, 
which  to  rough  observation  would  seem  to  contain  blood,  but  in  which, 
the  corpuscles  are  replaced  by  a  pulverulent  sediment  either  loosely  scat- 
tered or  more  or  less  shaped  by  tlie  kidney-tubes.  With  warmth  the  shiv- 
ering ceases,  the  urine  slowly  resumes  its  natural  character,  and  the 
patient  remains  free  both  from  the  shivering  and  the  hsematuria  until,  as 
happens  in  the  majority  of  cases,  an  accidental  chill,  or  as  is  the  manner 
with  some,  the  recurrence  of  the  period,  brings  a  repetition  of  the  pro- 
cess; Occasionally  Avith  the  attacks  the  skin  assumes  a  yel]>c)AV  tint  like 
that  of  slight  jaundice.     AVith  this  as  the  outline  of  a  t}^ical  case,  I 


INTERMITTENT    HEMATURIA    OR    H^MO  GLOBINUKIA.  275 

will  proceed  to  fill  in  from  my  own  observation  and  that  of  others  such 
details  as  have  as  yet  been  brought  within  our  view. 

Front  as  early  as  the  year  1825  '  alludes  to  an  instance  of  obstinate 
hgematuria  in  which  the  bleeding  was  constantly  preceded  by  a  shivering 
fit.  In  the  later  editions  of  his  work  *  he  enlarges  upon  malaria  as  a 
cause  of  this  form  of  hajmorrhage,  dwells  upon  "  the  multiform  degrees 
and  shapes  assumed  by  this  fearful  scourge,"  as  making  it  difficult 
justly  to  estimate  its  effect,  and  discusses  the  treatment  of  "  haematuria 
decidedly  connected  with  affections  of  malarious  origin,"  recommending 
the  mineral  acids,  quinine,  and  perchloride  of  iron. 

In  the  mean  while  the  subject  had  attracted  the  notice  of  others.  Dr. 
Elliotson  ^  described  a  case  of  irregular  ague  which  had  been  contracted 
in  the  Walcheren  expedition,  in  which  he  mentions  as  a  peculiarity  un- 
exampled in  his  experience  that  with  every  cold  fit  the  urine  became 
bloody.  There  were  also  symptoms  which  were  held  to  indicate  hyper- 
trophy of  the  heart,  but  the  bloody  urine,  says  Dr.  Elliotson,  was  inter- 
mitting like  the  rigors,  and  was  thought  to  belong  to  the  ague,  not  to 
the  cardiac  disturbance.     The  jiatient  recovered  under  quinine. 

In  the  year  1837,  Gergerc's'  reported  a  similar  case  as  one  of  quoti- 
dian hrematuria.  A  naval  captain  had  fits,  apparently  of  severe  ague, 
in  which  he  passed  blood  instead  of  urine.  These  attacks  recurred  at 
tlie  same  hour  for  three  successive  days,  and  they  were  cured  by  large 
doses  of  quinine.  More  recently  the  conjunction  of  aguish  symptoms 
with  haBmaturia  was  referred  to  by  Sir  Thomas  Watson,"  with  the  men- 
tion of  a  case  within  his  own  experience  in  which  this  discharge  was 
always  marked  by  a  smart  rigor. 

Details  have  since  been  added  to  these  broad  observations,  of  which 
the  most  important  is  the  distinction  between  the  intermittent  and  com- 
mon hematuria  in  the  absence  of  blood-corpuscles  in  the  discharge  be- 
longing to  the  former;  and  attention  has  lately  been  drawn  by  Dr. 
Wickham  Legg "  to  a  paper  by  Dressier,'  published  in  the  year  1854, 
which  had  hitherto  escaped  notice,  in  which  this  and  other  particulars 
of  the  disorder  were  pointed  out  and  the  names  Intermittent  Albuminu- 
ria and  Chromaturia  employed. 

More  recently  fresh  attention  was  drawn  to  the  subject  by  two 
jmpers  Avhich  were  read  on  the  same  evening  at  the  Medico-Chirurgical 
Society  (May  9th,  1865).  The  first  read  and  first  contributed  was  by  Dr. 
George  Harley,  the  second  by  myself.  These  recorded,  with  micro- 
scopic details  not  hitherto  attainable,  cases  which  had  been  observed  in- 
dependently. The  attention  thus  drawn  to  the  curious  particulars  of 
the  disease  was  followed  by  the  publication  of  many  instances  which  at 
this  date  it  is  not  necessary  to  enumerate,  but  of  which  a  list  up  to  the 
year  1874  may  be  found  in  Dr.  ^Yickham  Legg's  paper  to  which  I  have 
referred.  My  own  experience,  besides  fragmentary  observations,  is  re- 
presented by  21  cases,  of  which  I  have  tolerably  complete  notes,  and  in 

^  An  Inquiry  into  the  Nature  and  Treatment  of  Diabetes,  Calculus,  etc.,  26. 
edit.,  p.  299, 

^  On  Stomach  and  Urinary  Diseases,  3d  edit.  1840,  pp.  432  and  437. 
^  Lancet,  18:52.  vol.  i.  p.  oO(). 

*  Gazette  Medicate  de  Pai'is,  1838,  p.  151.     Quoted  from  Journal  de  Sociite 
Royale  de  Medecine  de  Bordeaux. 

*  Lectures  on  the  Principles  and  Practice  of  Physic,  4th  edit.,  vol.  ii.  p.  725. 

'  See  Paper  on  Paroxysmal  Hcematuria,  by  Dr.  Wickham  Legg,  Bartholomew 
Hospital  Reports  for  1874. 

''Dressier,  Arch,  f  Path.  Anat.,  1854. 


276  INTERMITTENT    HEMATURIA    OR    H.EMO-GLOBINURIA. 

AV'hich  the  nature  of  the  complaint  was  beyond  doubt,  though  in  two  of 
them  I  did  not  see  the  urine  under  the  paroxysm.  I  shall  appeal  to 
these  as  presenting  facts  for  which  I  can  vouch,  and  experience  which  is 
for  the  most  part  unrecorded. 

First  as  regards  sex  and  age:  of  my  21  cases  15  related  to  males,  G  to 
females.  In  age  the  subjects  when  brought  under  notice  varied  from  3 
to  48  years.  4  were  between  3  and  5  years  of  age;  one  9;  one  10;  one  19. 
Afterwards  the  disorder  was  distributed  between  the  ages  of  25  and  48 
without  great  inequality.  The  earliest  age  at  which  the  disease  has 
been  observed,  according  to  Dr.  Legg's  inquiry,  is  2  years;  the  latest  at 
which  it  has  been  known  to  commence,  52. 

Next  as  to  the  antecedents  of  the  disease  and  of  its  attacks.  As 
preceding  the  liability,  the  influence  of  malaria  is  to  be  traced  more 
often  than  any  other,  though  by  no  means  always;  while  cold  with 
much  constancy  is  the  excitant  of  the  attacks.  As  to  malaria,  careful 
inquiry  among  the  21  cases  I  have  referred  to  gives  the  following  re- 
sults: In  3  there  had  been  tertian  ague.  In  2  there  had  been  fever, 
which  was  described  as  of  malarial  origin,  but  which  was  less  exactly  de- 
fined. As  to  the  16  cases  in  which  no  intermittent  or  malarial  fever  had 
been  recognized,  they  were  thus  circumstanced  as  regards  the  marsh 
poison.  Two  patients  had  formerly  lived  in  households  others  members 
of  Avhich  had  had  ague;  one  with  a  brother  at  Waltham  Abbey,  who  died 
with  it;  one  in  a  village  near  Tunbridge  where  two  uncles  had  it.  Three 
had  lived  or  worked  where  there  was  evidence  or  suspicion  of  malaria  of 
a  less  direct  kind;  one  at  Barking  in  Essex;  another  used  to  go  harvest- 
ing to  the  Essex  marshes,  and  sleep  in  a  barn.  And  I  have  made 
esi^ecial  mention  of  the  case  of  a  man  who  was  attacked  with  the  dis- 
ease, and  apparently  contracted  it,  while  digging  foundations  at  Char- 
ing Cross  in  the  ancient  bed  of  the  Thames.  It  is  notorious  that 
newly  exposed  soil  in  a  malarious  district  is  especially  dangerous.  Be- 
side these  instances  in  which  a  malarial  influence  may  be  regarded  as 
ascertained,  there  are  others  in  which  it  may  be  suspected.  Five  came 
from  the  immediate  vicinity  of  the  Thames  in  AVestminster,  Pimlico, 
Bermondsey,  and  Oxford.  Two  came  from  Haverstock  Hill,  where, 
according  to  the  testimony  of  one  of  them,  ague  was  known.  I  have 
ascertained,  however,  from  Dr.  Coffin,  Avho  practises  in  that  neighbor- 
hood, that  though  there  have  undoubtedly  been  cases  of  ague  there  they 
have  apparently  all  been  imported.  Putting  aside,  therefore,  the  Haver- 
stock Hill  cases,  but  including  those  from  the  banks  of  the  Thames,  there 
are  out  of  the  21  cases  15  in  which  there  had  been  a  history  of  ague  or 
a  probability  of  exposure  to  malaria.  I  may  mention  in  connection  with 
this  origin  of  the  disease  that  a  late  physician  who  suffered  fi'om  the 
disorder  but  did  not  consider  it  to  have  had  this  this  source,  was  born  at 
Hythe  in  Kent,  where  ague  was,  and  probably  is,  well  known. 

I  have  preferred  to  appeal  to  cases  which  I  have  myself  inquired  into 
with  this  end  in  view,  but  I  might  adduce  evidence  to  the  same 
purport  from  other  sources.  I  find  that  among  22  published  instances 
taken  without  selection  ague  is  mentioned  as  an  antecedent  in  0.  But 
I  think  it  is  clear  that  the  precedence,  often  remote,  of  malaria  must  be 
admitted  in  many  cases  where  ague  has  not  been  definitely  declared.  In 
some  cases  the  malarial  fever,  as  in  the  case  of  Catherine  Evans, 
has  been  accompanied  or  immediately  succeeded  by  the  h^ematuria,  but 
more  often  there  has  been  an  interval  between  the  two  affections,  in 
one  of   my  patients,  one  of  3  years,  in  another  of  9  years,  in  a  third 


INTERMITTENT   HEMATURIA    OR    H.EMO-GLOBINURIA,  277 

of  14  years.  In  one  instance  mentioned  by  Dr.  Ilarley  a  West  Indian 
intermittent  had  not  subsided  when  the  htematuria  commenced;  one 
of  Dr.  Roberts's  patients  who  had  repeatedly  had  ague,  also  in  the 
West  Indies,  lost  it  two  years  before  the  later  complaint  declared  itself. 
The  disease,  also,  as  has  been  made  sufficiently  clear,  may  ensue  upon 
malarial  exposure  without  the  intervention  of  anything  that  can  be 
recognized  as  ague.  We  have  evidence  in  those  cases  where  the 
haematuria  has  immediately  succeeded  upon  ague  that  malaria  is  able 
by  itself  to  sot  up  the  condition  in  question,  while  in  others,  and  those 
the  more  frequent,  this  agency  presents  itself  rather  as  a  predisposing 
than  the  exciting  cause.  But  it  is  present  in  one  guise  or  another  so 
frequently  that  considering  the  tenacity  of  the  malarial  influence,  its  in- 
sidious and  often  latent  character,  and  the  certainty  that  it  is  often 
present  where  it  cannot  be  traced,  it  must  be  allowed,  that  this  is,  to 
say  the  least,  the  most  frequent  of  the  causes  to  which,  whether  pre- 
disposing or  exciting,  this  peculiar  form  of  hfematuria  is  to  be  at- 
tributed. 

The  disease  presents  itself  almost  invariably  without  any  suspicion  of 
heredity.  It  has  been  known,  at  least  in  one  instance,  to  occur  m  two 
generations — a  young  man  had  h^emoglobinuria  and  much  enlargement  of 
the  spleen,'  his  sister  presented  traces  of  hfemoglobin  in  the  urine,  but  had 
no  enlargement  of  the  spleen.  Their  father  had  passed  dark  urine  and 
died  with  a  spleen  weighing  7  pounds.  The  organic  enlargement  in 
father  and  son  would  at  least  suggest  the  possibility  that  both  may  have 
been  malarial,  and  the  disease  endemic  rather  than  hereditary. 

Instances  have  been  reported  in  which  violence  or  exertion  have 
appeared  to  be  concerned  in  the  production  of  the  disease.  Sir  W.  Gull 
mentions  that  of  a  young  lady  in  which  the  peculiar  condition  of  urine 
followed  an  injury  to  the  back  in  a  fall  in  getting  into  a  railway  carriage. 
Eosenbach  has  reported  a  case  in  which  the  first  attack  succeeded  upon  a 
fall  from  a  wagon,  though  recurrences  were  induced  by  exposure  to 
cold.  A  case  is  recorded  by  Fleischer  in  which  hemoglobinuria,  unac- 
companied by  shivering  or  sweating,  appeared  in  a  soldier  first  after  a 
long  march,  and  recurred  as  the  result  of  walking,  not  from  stationary 
exercise  or  from  cold. 

Among  the  other  antecedents  of  the  disease  which  require  mention 
are  syphilis  and  alcoholism,  but  it  is  to  be  questioned  whether  either  is 
really  concerned  in  its  production.  Among  my  21  cases,  mostly  men  of 
the  hospital  class,  there  was  evidence  of  syphilis  in  6,  perhaps  not  more 
than  might  in  any  circumstances  have  been  reckoned  upon.  As  to  alco- 
hol, it  presented  itself  apparently  as  the  exciting  cause  in  two  cases,  in 
one  of  which  the  disorder  presented  itself  during  a  debauch;  in  the  other 
the  bloody  urine  was  said  to  have  been  first  passed  immediately  after  in- 
toxication. In  one  of  these  there  was  no  malarial  history;  in  the  other 
there  had  been  malarial  exposure  but  no  ague.  In  both  there  had 
been  syphilis. 

In  one  or  two  instances  haemoglobinuria  has  succeeded  immediately  or 
remotely  upon  suppurative  conditions;  haemoglobinuria  does  not  present 
itself  with  the  lardaceous  state  so  common  a  result  of  suppuration;  and 
it  may  be  doubted  whether  the  evidence  is  sufficient  to  connect  this 
process  with  the  disease  in  question. 

'  Case  of  continued  Haemoglobinuria,  apparently  hereditary,  by  Dr.  Saundby, 
Med.  Times,  May  1st,  1880,  p.  476. 


2TS  INTERMITTENT    H.EMATURIA    OR    H-EMO-GLOBINURIA. 

The  excitant  of  each  attack  is  generally  cold;  but  the  actual  cause 
of  the  disease  must  be  sought  in  the  circumstances  which  have  rendered 
the  subject  of  it  liable  to  be  thus  peculiarly  influenced  by  an  agency 
which  commonly  produces  no  such  result.  Cold  with  intermittent  htema- 
turia  appears  to  stand  in  the  place  which  time  occupies  with  regard  to 
ague;  it  does  not  cause  the  disease,  but  determines  the  paroxysms. 

The  influence  of  cold  in  this  respect  is  one  of  the  most  striking  char- 
acteristics of  the  disease.  The  patient  is  well  so  long  as  he  is  warm. 
The  flit  beginning  with  rigors  is,  as  a  rule,  produced  immediately  by  a 
chill;  among  our  modern  instances,  however,  where  the  description  is 
minute  and  conclusive,  there  is  at  least  one  instance,  that  of  Dr. 
Druitt,  where  the  disorder  occurred  diurnally.  and  by  the  older 
writers  such  haemorrhagic  attacks  are  frequently  spoken  of  as  periodic. 

The  cold  by  which  the  sequence  of  symptoms  is  started  is  usually 
applied  in  some  obvious  manner,  and  is  productive  of  a  distinct  sense  of 
chill.  A  laborer  is  habitually  attacked  as  soon  as  he  goes  out  on  a  very 
cold  or  frosty  day.  The  same  man,  though  commonly  exempt  in  the 
summer,  once  brought  on  an  attack  in  warm  weather  by  cleaning  win- 
dows with  cold  water.  A  greengrocer  attributed  an  attack  to  his  having 
been  for  several  hours  on  a  cold  day  in  an  oj^en  shop;  a  laundress,  hers 
to  standing  all  day  in  a  damp  wash-house.  An  excursion  into  the  coun- 
try in  an  open  cart  instigated  a  seizure  in  another  instance.  A  sailor 
who  had  many  years  before  had  ague  in  Havannah  was  first  affected  b}' 
the  hfemorrhagic  disorder  during  seven  days  of  exposure  after  shipwreck. 
Some  persons,  however,  have  become  so  susceptible  in  this  respect 
that  waiting  in  a  cold  out-patient  room,  exposure  to  a  chance  draught, 
leaving  bed  in  an  attempt  at  convalescence,  drinking,  or  washing  the 
hands  in,  cold  water,  have  been  sufficient  to  re-initiate  the  morbid 
series. 

Thus  started,  a  fit  follows  which  might  be  taken  for  one  of  ague  with, 
however,  the  distinguishing  peculiarity  that  it  is  succeeded  by  the  dis- 
charge of  urine  which  contains  the  substance  of  blood,  and  displays  its 
color  but  not  its  shapes.  As  typical  of  the  commencement  and  course 
of  the  seizure,  I  may  adduce  the  habitual  experience  of  a  man  whose  case 
I  brought  before  the  Medical  and  Chirurgical  Society.  He  would  get  up 
and  go  to  his  work  as  a  builder's  laborer  api)arently  well.  If  he  hap- 
l^ened  to  get  chilled  he  would  very  shortly  be  attacked  with  shivering 
and  retching,  together  with  yawning  and  an  inclination  to  stretch  him- 
self, pain  in  the  loins  and  down  the  thighs,  and  retraction  of  the  testi- 
cles. Within  an  hour  or  so  he  would  pass  a  considerable  quantity  of 
black  urine,  and  the  pain  in  the  loins,  up  to  this  time  on  the  increase, 
would  gradually  subside,  and  the  constitutional  disturbance  cease.  When 
the  attack  came  on  he  used  to  leave  his  work  and  go  liome  and  to  bed, 
taking  care  to  be  very  warm.  The  urine  usually  retained  its  character 
for  two  or  three  times  of  passing  and  then  resumed  its  natural  appear- 
ance. The  attack  varied  in  length  from  three  to  twelve  hours.  It  was 
often  succeeded  in  the  evening  by  griping  or  colicky  pain  about  the  um- 
bilicus. Next  day  Aveakness  and  pallor  were  the  only  remnants  of  the 
attack,  and  upon  recovery  from  these  he  remained  without  ailment  until 
after  an  uncertain  interval  the  process  was  repeated. 

In  the  larger  number  of  instances  the  sanguineous  discharge  has 
ceased  after  two  to  three  emptyings  of  the  bladder,  or  even  with  one,  the 
whole  attack  being  comprised  within  the  period  of  twenty-four  hours. 


INTERMITTENT  HEMATURIA   OR   H^MO-GLOBINURIA.  279 

In  others  the  hnemorrhage  has  continued  for  several  days,  with  little 
alteration. 

It  has  frequently  been  observed  that  under  the  attack  the  patient  has 
become  jaundiced  or  yellow.  It  is  probable,  however,  that  the  discolora- 
tion has  nothing  to  do  with  the  secretion  of  bile,  but  is  a  tinting  of  the 
skin  by  the  hgematin  which  is  set  free.  And  not  only  may  hsematin  be 
thus  generally  diffused,  but  local  haemorrhages  have  been  known  to 
occur  in  the  shape  of  purpura,  and  there  is  at  least  clinical  reason  to 
suppose  that  effusions  of  blood  or  of  some  of  its  material  sometimes  take 
place  into  the  joints  or  cellular  tissue. 

"When  beginning  with  a  marked  rigor,  yawning,  retraction  of  the 
testicles,  and  pain  in  the  loins  and  thighs  are  seldom  wanting.  The 
attacks  are  most  apt  to  come  on  in  the  early  part  of  the  day,  though  they 
do  not  invariably  do  so.  A  patient  assured  me  that  he  could  bear  in 
the  evening  with  impunity  an  exposure  which  in  the  morning  would 
never  fail  to  bring  on  an  attack.  In  some  cases  the  coldness  and  lividity 
of  the  extremities,  or  of  the  nose  or  cheeks,  in  the  beginning  of  the 
attack,  have  been  almost  as  if  the  parts  were  about  to  mortify.  Dr. 
Druitt  describes  his  face  as  spotted  with  blue-like  patches  of  incipient 
gangrene.  And  it  has  been  observed,  from  whichever  point  of  view  Ave 
regard  the  concurrence,  that  together  with  the  attacks  of  local  coldness 
and  arrest  of  circulation  followed  by  symmetrical  gangrene,  and  described 
by  Eeynaud,  haemoglobinuria  has  occurred. 

When  repeated  in  a  severe  form  the  patient  is  apt  to  become  pallid 
from  loss  of  blood,  or  may  present  a  yellowish  or  earthy  complexion. 
Loss  of  sexual  power  has  been  noted,  as  in  a  case  reported  by  Mr. 
Neale. ' 

Urticaria  sometimes  appears  in  connection  with  the  disease.  Dr. 
Forrest^  has  recorded  an  instance  in  which  a  sufferer  from  hgemoglobin- 
urla  often  had  patches  of  the  same  nature  after  washing  in  cold  water  or 
exposure  to  rain  or  a  cold  wind.  The  concurrence  has  been  held  to  in- 
dicate a  nervous  origin  for  the  urinary  disorder,  and  from  another  point 
of  view  may  be  taken  to  associate  it  with  ague  and  with  Eeynaud's  dis- 
ease, in  connection  with  both  of  which  this  eruption  has  been  known  to 
present  itself. 

The  attacks  vary  in  degree  from  severe  rigor  and  profuse  hasmorrhage 
to  a  transient  chilliness,  succeeded  by  urine  which  is  merely  lithatic  or 
but  slightly  discolored.  Even  with  the  slighter  forms,  however,  the 
complexion  may  be  yellowish,  sallow,  or  earthy.  Such  abortive  attacks, 
in  which  there  is  no  rigor  but  07ily  an  approach  to  one,  and  in  which  the 
urine  becomes  only  lithatic,  ofte  present  themselves  in  the  place  of  the 
more  complete  fits  when  the  mplamt  is  on  the  decline;  and  possibly 
such  mutilated  symptoms  may  be  the  only  evidence  of  the  disease  in  an 
obscure  form  in  which  it  sometimes  presents  itself. 

The  range  of  temperature  under  the  attack  is  generally  lower  than 
that  of  ague,  and  the  fluctuation  smaller,  though  some  instances  have 
been  recorded  in  which  both  in  level  and  variation  the  ha^maturic  chart 
has  closely  resembled  that  of  the  more  common  intermittent.  With  a  fit 
of  ordinary  ague  the  temperature  begins  to  rise,  as  the  first  intimation 
that  the  cold  fit  is  beginning,  and  continues  to  mount  until  the  sweating 


'  Lancet,  Nov.  1879.  p.  725. 
"  Glasgow  Med.  Journal,  1879 


280  INTERMITTENT    H-EMATURIA    OR    H^MO-GLOBINURIA. 

period,  when  it  descends  rapidly.  With  intermittent  haematnria  it  has 
frequently  been  noted  that  the  temperature  is  lower  than  normal  in 
the  cold  stage,  and  the  elevation  on  its  termination  small  or  unol;serv- 
able. 

In  Dr.  Harley's  case,  the  temperature  in  the  axilla  during  the  cold 
stage  was  96.1°.  In  one  recorded  by  Dr.  Eoberts,  the  thermometer  in 
the  same  situation,  at  the  same  period  of  the  attack,  marked  96.6'';  a 
few  minutes  afterwards  the  patient  passed  bloody  urine,  and  five  minutes 
later  said  he  felt  quite  well,  and  displayed  a  temperature  of  98.6°.  Dr. 
Druitt,  after  a  statement  of  the  large  variations  which  he  underwent  in 
some  paroxysms  of  apparently  ordinary  ague  with  which  his  disorder  was 
complicated,  remarks  that,  with  these  exceptions,  the  temperature  of  the 
mouth  and  axilla  were  steadily  98.4°.  Thus,  in  some  cases,  unlike  what 
occurs  in  ague,  it  is  clear  that  the  cold  stage  is  one  of  actual  coldness, 
while  in  others  there  is  at  least  no  abnormal  heat. 

Other  examples,  however,  present  more  of  the  aguish  character  in 
this  respect.  One  of  Dr.  Greenhow's  patients  gave  under  the  rigor  on 
three  occasions  temperatures  which  varied  from  100''  to  100.4°;  while 
after  the  rigor  it  was  once  found  to  have  reached  103.2'.  Added  to  this, 
the  attack  has  in  several  instances  been  succeeded  by  profuse  sweating, 
so  that  at  least  sometimes  the  pyrexial  character  of  the  haematuric 
paroxysm  has  been  marked  and  the  resemblance  to  ague  obvious.  It  is 
not  improbable  that  in  all  attacks  which  are  sufficiently  acute  to  be  at- 
tended with  a  cold  stage,  the  temperature,  however  low  at  first,  must 
rise  as  the  fit  goes  on,  and  so  present  some  sort  of  parallelism  to  that  of 
ague,  however  much  lower  may  be  the  general  level  of  the  curve  and  less 
marked  the  fluctuations.  It  is  worth  noting  that  in  two  of  the  cases 
presently  recorded — those  of  Dare  and  Dr.  Druitt — venous  coagula  were 
formed  in  the  limbs. 

Other  disorders  may  attack  the  subjects  of  this  disease  and  run  their 
course  independently  of  it;  instances  are  recorded  in  which  diphtheria, 
quins}',  and  measles  have  thus  presented  themselves,  the  last  Avith  a  fatal 
issue;  pneumonia,  in  one  case,  came  on  while  the  patient  was  in  the 
hospital,  as  if  connected  in  some  way  with  the  disease  or  its  treatment; 
and  it  is  to  be  observed  that  this  disease  was  the  immediate  cause  of  the 
death  of  Dr.  Druitt,  though  not  obviously  connected  with  hsemoglobin- 
uria.  Perhaps  the  only  disorder  to  be  traced  as  a  direct  result  of  that 
condition  is  nephritis,  of  which  association  more  than  one  instance  has 
come  under  my  observation. 

To  comprise  in  a  few  sentences  what  is  known  of  the  condition  of  the 
urine  in  this  disorder,  the  secretion  in  the  intervals  of  the  attack  is  ab- 
solutely natural.  With  the  attack  it  suddenly  assumes  a  color  which  is 
ostensibly  due  to  the  admixture  of  blood,  though  the  range  of  tints,  how- 
ever deep,  is  rather  vinous  than  red,  smoky  or  black,  as  with  other  forms 
of  hfematuria.  The  urine  is,  on  standing,  divisible  into  two  portions,  a 
bright  superstratum,  perhaps  of  the  color  of  port  or  burgundy,  or  of  the 
lighter  tint  of  brown  sherry  or  Madeira.  This  is  coagulable  with  heat 
and  acid  to  a  greater  or  less  extent,  usually  giving  a  dark  brown  floating 
clot  in  which  most  of  the  coloring  matter  is  comprised.  The  coagulum 
produced  by  heat  is  sometimes,  but  by  no  means  constantly,  largely  dis- 
solved by  nitric  acid.  The  solubility  of  albumin  in  nitric  acid  admits 
of  great  variation.  Paraglobulin,  as  estimated  by  precipitation  with 
sulphate  of  magnesia,  is  usually  present,  though  in  much  smaller 
quantity  than  the  albumin  (see  cases  of  King  and  Collingbourne).     After 


LNTEEMITTENT    HEMATURIA    OR    H.E.MO-GLOBINURIA.  281 

the  urine  has  resumed  a  natural,  or  nearly  natural,  appearance,  tlie  guaia- 
cum  test  will  often  give  the  blue. 

Many  observations  with  the  spectroscope  have  been  made  of  late 
upon  urine  under  the  peculiar  form  of  haemorrhage  in  question.  Haemo- 
globin or  oxyhgemoglouin  has  been  always  found  together  with,  in  some 
instances,  methtemoglobin.  In  the  urine  of  Taylor  under  an  attack  Dr. 
Stone  found  the  double  absorption  band  of  oxydized  htemoglobiu.  Drs. 
Forrest  and  Finlayson  in  similar  cases  found  similar  evidence  together 
with  that  of  methsemoglobin  or  acid  hsematin  ;  and  we  have  much  other 
testimony  to  the  same  purport — hgemoglobin  being  constant  and  methae- 
moglobin  occasional.'  I  have  of  late  habitually  examined  specimens  of 
urine  under  this  disease  with  a  large  pocket  spectroscope  recommended 
by  Mr.  Browning  for  the  purpose.  Oxyhtemoglobin  has  never  failed  to 
present  itself  when  the  blood  was  fairly  abundant.  I  have  not  recog- 
nized methsemoglobin.  The  spectroscope  as  a  test  for  blood,  whether 
corpuscular  or  disintegrated,  appears  to  be  inferior  in  delicacy  to  others. 


Nearly  amorphous  translucent  web  of  fibrin  imbedding  sparkling  specks  and  casts.  From 
urine  <}f  a  bo}»5  years  old  during  an  attack  of  intermittent  haematuria. 

The  sediment  examined  with  the  microscope  consists  of  two  compo- 
nents: first,  a  translucent  filmy  expanse,  which  has  no  more  structure 
than  the  non-corpuscular  basis  of  mucus,  or  the  fibrinous  sliape  which 
belongs  to  the  most  delicate  form  of  tube-casts;  secondly  granules  which 
the  first  imbeds.  The  web  is  soluble  in  potash  and  acetic  acid,  and 
probably  consists  of  coagulated  fibrin.  The  granules  entangled  in  it 
may  be  too  small  for  recognition,  excepting  as  a  fine  brown  powder;  but 
in  many  instances  this  is  mixed  with  crystalline  or  crystalloid  masses  of 
a  yellow  color,  closely  resembling  the  blood-crystals  often  found  in  the 
pia  mater  and  elsewhere.  Frequently,  where  no  crystalline  shapes  are 
to  be  discovered,  much  of  the  deposit  presents  itself  as  sparkling  gran- 
ules, which  are  suggestive  of  crystalline  structure,  though  too  small  to 

'  Forrest  and  Finlayson,  Glasgow  Med.  Journ.  1879;  Neale,  Lancet,  Nov.  1879, 
p.  725;  M.  Cazeneuve,  Lyon  Med.,  1880,  vol.  xxxix.,  p.  89. 


282 


INTERMITTENT   H^EMATDRIA    OR   H^MO  GLOBINURIA. 


be  identified.     In  two  of  the  cases  I  have  referred  to  as  under  my  own 
observation  distinct  crystals  or  crystalloid  particles  were  found;  in  four 


^.:^:'^  -.  W 


C'Vl^A^      0-..0"'-- 


cS 


Urinary  deposit  in  case  of  Edw.  Harvey,  April  1st,  1878.  Fine  pranular  matter  interspersed 
•with  bright  yellow  crystalloid  masses,  apparently  blood -crystals.  Two  of  these  are  represented 
black.    Also  granular  casts  and  leucocytes.    From  drawing  by  the  late  E.  H.  Cowburn. 

refracting  specks,  possibly  of  the  same  nature.     The  larger  masses  as 


N€» 


Mj0 


^Vi^ 


*n%^2s 


C^'^^-^J^ 


5^ 


m 


^^' 


^  -j^V./:."— 


Urinary  deposit  from  John  Dare,  aged  34,  with  intermittent  haematuria.  Yellow  translucent 
crystalloid  masses,  api)arently  imperfect  blood-crystals,  sprinkled  through  a  faintly  j-ellow  finely 
granular  web  of  irregular  outline.    No  definite  casts.     XOOO  D. 


seen  under  the  eighth  were  distinct,   strongly  yellow  and  translucent. 


INTERMITTENT    HEMATURIA    OR    H^MO-GLOBINURIA. 


283 


obviously  blood-crystals,  though  generally  irregular  or  rounded  in  out- 
line. In  one  well-marked  instance  I  found  them  to  be  soluble  in  liquor 
potassae,  not  in  acetic  acid,  as  would  be  the  case  did  they  consist  of 
haemin  or  oxy-h£emoglobin.  Taking  their  characters,  together  with  the 
spectroscopic  evidence  as  to  the  urine,  it  is  probable  that  they  should  be 
called  oxyhfemoglobin,  though  the  point  is  one  upon  which  further  ob- 
servations are  needed.  Sir  W.  Gull '  described  them,  in  a  case  under  his 
own  care,  as  prismatic  crystals  of  hgematin. 

Next  to  the  presence  of  disintegrated  blood  prominence  must  be  given 
to  the  absence,  complete  or  nearly  so,  of  corpuscles.  Sometimes  a  few 
red  corpuscles  are  to  be  seen,  especially  in  the  later  stages  of  each  at- 
tack, as  if  the  modified  hasmorrhage  were  succeeded  or  accompanied  by 


Urinary  deposit  in  case  of  Cath.  Evans  from  June  8th  to  27th.  Amorphous  brown  granular  mat- 
ter held  together  by  a  faint  translucent  web.  Many  renal  cells  tinted  of  intense  Drown  color. 
Casts  containing  brown  granular  matter  and  epithelium.  One  was  filled  with  translucent  specks 
of  yellow  blood-pigment.  Uric  acid  crystals  were  seen,  but  are  not  represented;  neither  are  a  few 
blood-corpuscles,  whic^li  were  found  in  the  later  examinations  only.  Generally  magnified  260  D. 
Two  cells  of  renal  epithelium  and  the  cast  to  their  left  are  magnified  500  D. 

traces  of  ordinary  haemorrhage;  occasionally  also  a  few  leucocytes  are 
associated  with  the  other  deposits;  but  such  evidences  of  the  escape  of 
unaltered  blood  are  trifling  and  probably  secondary,  and  it  frequently 
happens  that  not  a  single  blood-corpuscle  can  be  seen  at  any  period  in 
the  course  of  the  paroxysm.  As  an  exception  to  these  statements  I 
may  refer  to  the  case  of  King,  in  which  the  disintegrated  discharge 
occurred  at  one  time  and  at  another  one  wholly  corpuscular,  and  I  might 

'  A  case  of  intermittent  haeniaturia.      Guy's  Hospital  Reports  for  1866,  p.  381. 


284  INTERMITTENT    HJEMATDRIA    OR    H^MO-GLOBINURIA. 

refer  to  other  cases  in  which  considerable  ordinary  haemorrhage  has  oc- 
curred together  with  or  after  the  peculiar  flux. 

Mixed  with  the  brown  powder}'  sediment  which  has  been  described, 
and  often  chiefly  composed  of  it,  are  casts  of  the  renal  tubes,  usually 
somewhat  narrow,  as  if  the  pulverulent  material  of  which  they  are  made 
had  been  moulded,  together  probably  with  some  recognizable  flbrin,  in 
the  normal  channels.  Besides  such  casts,  hyaline  and  epithelial  kinds 
may  often  be  seen  in  considerable  variety,  should  the  special  attack  be 
succeeded,  as  often  ha])pens,  by  a  transient  condition  of  renal  inflamma- 
tion. In  such  cases  renal  epithelium  is  often  found  stained  of  a  deep 
brown  color.  Oxalate  of  lime  and  crystals  of  uric  acid  are  found,  the 
former  frequently,  the  latter  occasionally.  Amorphous  lithates  are  gen- 
erally present,  and  that  abundantly,  in  succession  to  the  haemorrhagic 
products  as  the  attack  is  subsiding.  Lithates  may  also  present  them- 
selves as  substitutes  for  these  products  in  the  imperfect  or  abortive  at- 
tacks which  are  apt  to  occur  on  the  decline  of  the  disorder. 

Attention  has  been  directed  rather  to  the  abnormal  than  the  normal 
constituents  of  the  urine  since  the  alterations  are  chiefly  by  way  of  addi- 
tion. Under  the  paroxysm  the  diurnal  quantity  appears  to  be  usually 
increased,  as  also  is  the  specific  gravit3^  In  Dr.  Druitt's  case,  in  which 
the  paroxysms  were  quotidian,  the  quantity  ranged  during  7  days  from 
40^  to  67  ounces;  the  sp.  gr.  from  1.007  to  1.028,  generally  higher  when 
the  sanguineous  discharge  was  present  than  when  it  was  not.  My 
patient,  Parker,  passed  on  the  day  of  a  severe  fit  1,525  CO.,  which  was 
his  maximum  as  compared  with  other  days,  though  not  a  marked  in- 
crease. The  specific  gravity  was  taken  for  every  urination  during  a 
week  for  which  the  urine  was  sometimes  bloody  and  sometimes  not. 
The  average  sp.  gr.  for  16  observations  on  which  the  urine  was  bloody 
was  1.015;  for  22  observations  on  Avliich  it  was  clear  it  was  1.011.  In 
a  case  I  published  in  the  "  Medico-Chirurgical  Transactions'"  the  spe- 
cific gravity  of  the  bloody  urine  was  1.025;  the  next  urination,  which 
was  natural,  had  a  specific  gravity  of  1.009.  With  regard  to  the  urea 
during  the  paroxysm  observations  conflict.  In  Dr.  Harley's  cases  *  it 
was  in  increased  proportion  in  the  bloody  urine,  in  one  3.6  per  cent,  in 
another  2.5  per  cent;  the  urine  in  the  latter  instance  presenting  before 
and  after  the  attack  the  percentages  of  1.7  and  1.8  only.  In  my  case,* 
published  in  the  same  volume,  the  percentage  of  urea  during  two  par- 
oxysms Avas  found  to  be  2.35  and  4.25  respectively,  while  in  an  interval 
it  was  1.6  per  cent.  Later  observations  have  given  different  results. 
In  Dr.  Druitt's  case  the  urea  during  the  paroxysms  for  three  consecu- 
tive days  ranged  from  1.00  to  1.10  percent,  while  two  specimens  of  clear 
urine  passed  after  the  fit  gave  percentages  of  1.62  and  2.26.  The  uric 
acid  in  Dr.  Druitt's  case  was  somewhat  diminished  during  the  paroxysm, 
increased  on  its  subsidence.  It  is  a  matter  of  common  observation  that 
lithates  are  often  superabundant  after  the  blood  has  ceased  to  appear. 
Observations  are  wanting  as  to  the  mineral  salts.  In  my  case  the  chlo- 
ride of  sodium,  both  during  the  ])aroxysm  and  afterwards,  was  somewhat 
low;  .45  per  cent  in  the  bloody  urine,  .5  per  cent  in  the  clear. 

Some  details  may  be  referred  to  in  the  case  of  Collingbourne,  which 
show  that  the  variations  of  quantity,  specific  gravity,  and  urea  as  be- 
tween the  fit  and  the  interval  were  not  constant;    the  phosphoric  acid 

'  Med-Chir.  Trans,  for  1865,  p.  161. 
''Ibid.,  p.  175. 


INTKRMITTENT    H>EMATURIA    OR    H^MO-GLOBINURIA.  285 

was  generally  increased  in  the  24  hours  which  included  the  fit.  the  chlo- 
ride somewhat  diminished,  though  during  the  haemorrhage  this  con- 
stituent displayed  a  larger  percentage  than  immediately  after  it.  The 
indigo  or  similar  pigment  was  seen  in  several  of  the  appended  cases  to 
be  much  increased  both  during  the  hccmorrhage  and  in  its  absence. 

The  blood  and  serum  have  been  examined  under  attacks  of  this  dis- 
ease with  results  which,  though  as  yet  scanty,  are  enough  to  show  that 
products  of  corpuscular  dissolution  are  present  in  the  general  circula- 
tion. Eed  blood-corpuscles  withdrawn  from  a  frigid  great  toe  at  the 
outset  of  a  paroxysm  have  been  described  by  Professor  Murri  '  as  dis- 
torted or  deformed,  while  the  surrounding  serum  displayed  granular 
material.  Further,  blister  fluid  produced  during  an  attack  has  been 
found  to  give  evidence  of  hajmoglobin.''  Besides  these  significant  obser- 
vations the  ordinary  blood  conditions  of  ansemia  have  been  found  to  be 
j^resent  in  this  disease. 

With  regard  to  the  morbid,  anatomy  of  this  disorder  a  case  which  was 
concluded  by  a  post-mortem  examination  is  related  in  an  earlier  part 
of  this  work,  in  which  the  symptoms  of  it  were  somewhat  equivocally 
associated  with  those  of  acute'  nephritis.  Beyond  that  my  own  experi- 
ence is  limited  to  four  instances. 

I  may  now  refer  to  a  case  which  presents  the  state  of  the  organs 
twenty-five  days  after  a  paroxysm.  The  particulars  may  be  condensed 
into  the  statement  that  there  was  intense  injection,  particularly  about 
the  junction  of  the  cones  and  cortex,  and  several  evidences  of  extravasa- 
tion, the  most  marked  of  which  was  an  interstitial  mass  of  blood,  of  ir- 
regular shape,  three  or  four  times  the  diameter  of  a  Malphighian  body. 
The  extravasations  appeared  to  be  chiefly  of  arterial  origin  and  to  con- 
sist mainly  of  corpusles,  but  in  part  of  granular  matter,  apparently  the 
result  of  their  disintegration.  I  shall  place  next  an  instance  in  which  death 
occurred  two  months  after  the  cessation  of  a  severe  and  long-continued 
hemorrhage  of  the  kind  in  question,  which  was  sequent  upon  malarial 
fever.  Extravasations  were  found  in  many  parts,  whether  connected  with 
intermittent  hematuria,  or  directly  with  malaria;  there  were  corpuscular 
extravasations  in  the  liver  and  a  preposterous  quantity  of  blood-pigment  in 
the  spleen,  as  shown  in  woodcut,  p.  286.  The  kidneys  were  marked  by 
intense  injection,  and  contained  minute  extravasations  in  connection 
both  with  the  cones  and  cortices,  the  most  striking  of  which  surrounded 
a  Malpighian  body,  as  represented  in  Avoodcut,  p.  28G.  The  extravasa- 
tions appeared  to  be  wholly  corpuscular,  both  of  red  and  white.  There 
were  evidences  of  tubal  and  interstitial  nephritis,  and  the  tubes  con- 
tained granules  of  blood-pigment.  Together  with  these  facts  I  must 
revert  to  the  remarkable  case  of  congestive  nephritis  related  in  an  earlier 
part  of  this  work,  which  presumably  took  its  origin  in  the  intermittent 
condition,  though  the  clinical  evidence  was  not  complete  on  this  point. 
The  kidneys  were  not  only  intensely  congested,  but  Taoth  had  burst  their 
capsules,  with  much  superficial  extravasation,  an  exceptional  result  of 
renal  disease  which  cannot  but  point  to  a  connection  between  that  case 
and  those  more  recently  adduced.  In  this  case,  in  addition  to  the  tubal 
and  interstitial  results  of  acute  nephritis,  many  of  the  tubes  were  lined 


'  Professor  Murri,  Emoglobinuria  da  Freddo.     Bologna,  1880. 
■Fleischer,  Berl.  Klin.  Wochenschrift,  1881,  No,  47.     Hayem;  case  by  Mesnet, 
Archives  Generales  de  Medecine,  May,  1881,  p.  513. 


286 


INTERMITTENT    H.EMATUKIA    OR    H.EMO-GLOBINURIA. 


•with  black,  granular  matter,  evidently  blood,  for  the  most  part,  though 
not  entirely  deprived  of  its  corpuscular  shape. 

Since  these  cases  have  occurred  several  other  post-mortem  examina- 


mm 


m^ 


;:^f"»i- 


:.£) 


'^ 


.^cQ^'S:- 


^■r 


Hsemorrhage  around  a  Malpighian  body  and  about  the  adjacent  structures  in  case  of  Evans, 

tions  have  been  recorded,  but  none  which  throw  any  further  light  upon 
the  disease.  We  owe  two  to  Professor  Murri,  of  Bologna,  one  upon  a 
patient  also  syphilitic,  who  died  apparently  of  tuberculosis  seven  months 


Granules  of  pigment  in  spleen  in  case  in  which  haemoalobinuria  was  associated  with  malaria 
fever. 

after  his  last  attack  of  haemoglobinuria.  There  was  general  miliary 
tuberculosis.  The  kidnerys  were  of  unequal  size;  the  left  natural  to  the 
naked  eye,  excepting  a  few  tubercles,  the  right  hypersemic  and  with  an 


INTERMITTENT    H.EMATURIA    OR    H^MO-GLOBINURIA.  287 

increased  cortex.  Upon  microscopic  examination  besides  the  tubercles 
which  were  present  in  both,  it  was  found  that  the  interstitial  tissue  was 
increased,  the  epithelium  in  some  parts  of  the  cortex  swollen  and  de- 
tached, and  collections  of  yellow  and  black  pigment  seen  in  the  cortical 
tubes. 

Taking  these  cases  together  "with  the  perfectly  natural  action  of  the 
kidney  often  observed  during  life  in  the  intervals  of  the  attacks,  we  may 
conclude  that  no  permanent  or  structural  change  either  of  the  kidney  or 
of  any  other  organ  is  necessarily  involved  in  the  disorder.  But  at  the 
same  time  interest  must  necessarily  attach  to  the  extravasations  which 
were  found  in  three  cases,  if  the  third,  in  which  the  capsules  were  thus 
ruptured,  may — of  which  there  seems  to  be  little  doubt — be  reckoned  as 
of  the  same  nature,  and  to  the  remarkable  and  intense  injection  which 
was  uniformly  observed  when  the  haematuria  was  of  recent  date.  We 
thus  may  regard  intense  renal  hyperaemia  frequently  accompanied  with 
extravasation  as  the  immediate  result  of  the  attack,  while  tubal  catarrh, 
interstitial  overgrowth,  and  chronic  fibrosis  are  to  be  traced  as  sometimes 
consequent  upon  it,  due  probably  to  the  repeated  congestion  which  the 
disease  involves.  The  renal  changes,  essentially  consisting  of  hyperemia 
which  is  usually  transient,  are  consistent  with  the  belief  that  the  dis- 
order is  primarily  of  the  blood,  the  kidneys  affected  only  as  the  channels 
of  elimination. 

With  the  facts  now  before  us  we  may  take  a  general  view  of  the  phe- 
nomena of  the  disease.  They  have  been  differently  interjireted.  Dr. 
George  Harley '  was  led  by  the  Jaundiced  appearance  to  infer  that  the 
attacks  were  in  some  way  connected  with  disturbance  of  the  hepatic 
function.  I  ventured  at  the  same  time'^  to  attribute  the  symptoms  to  a 
disintegration  of  blood-corpuscles  within  their  proper  vessels,  and  the 
subsequent  discharge  of  the  debris  by  the  kidneys  rather  than  to  any 
hepatic  or  primarily  renal  change.  The  view  which  thus  presented  itself 
nearly  twenty  years  ago  has  now  found  general  acceptance.  Sir  W. 
Gull  =*  held,  that  whatever  the  primary  change  might  be,  there  was  at 
least  good  evidence  that  the  kidneys  were  affected,  and  adduced  in  an 
instance  of  the  renal  source  of  the  disorder  the  case  of  a  lady  who  passed 
the  urine  characteristic  of  it  in  consequence  of  having  received  an  injury 
to  the  loins.  ^  Dr.  Greenhow,  the  next  commentator,  used  the  term 
dyscrasia  in  connection  with  the  disorder,  and  while  admitting  the 
evidences  of  renal  congestion  during  the  attack  which  are  sufficiently 
obvious,  accepted  the  view  which  placed  the  essential  change  in  the 
blood. 

Dr.  Stephen  Mackenzie,^  to  whom  we  are  indebted  for  an  able  and 
comprehensive  paper  on  the  disease,  though  formerly  he  thought  that 
the  corpuscular  destruction  occurred  in  the  kidney,  has  found  himself 
unable  to  resist  the  accumulated  evidence  that  it  takes  place  in  the  gen- 
eral circulation.  And  that  it  is  here  would  seem  now  beyond  doubt, 
since  the  products  of  corpuscular  dissolution,  hcTemoglobin,  and,  accord- 
ing to  Murri,  granular  matter,  have  been  found  in  the  serum  or  liquor 
sanguinis.  In  what  system  of  vessels  the  destruction  takes  place  may  be 
less  certain  than  the  fact  of  its  occurrence,  but  it  has  been  supposed 

^  Med.-Chir.  Trans.,  1865,  p.  170. 
^IbicL,  1865,  p.  183. 
3  Guy's  Hospital  Reports,  1866,  p.  390. 
*  Clin.  Soc.  Trans.,  1868,  p.  53. 
^Lancet,  1884,  vol.  i..  pp.  156,  198,  243. 


288  INTERMITTENT    HJEMATUBIA    OR    H.E.MO-GLOBINURI A. 

with  probability  to  come  to  pass  in  the  parts  of  the  body,  chiefly  the 
extremities,  the  blueness  and  coldness  of  which  mark  the  outset  of  the 
attack.  In  these  regions  of  local  cyanosis,  from  which  Professor  Murri 
infers  that  the  arterial  blood  is  shut  by  a  spasmodic  vascular  action,  he 
supposes  that  the  corpuscles  are  broken  down  by  the  combined  action  of 
cold  and  carbonic  acid,  to  be  eventually  eliminitated  by  the  kidneys. 

It  has  been  often  observed  that  a  feeling  of  general  illness  precedes 
any  urinary  change,  any  lumbar  pain  or  renal  symptoms.  The  rigor 
probably  marks  the  time  of  contamination.  A  rigor,  says  John  Hunter, 
is  commooly  the  first  symptom  of  a  constitutional  affection.  And 
whether  the  poison  be  febrile  or  septic,  the  truth  expressed  is  one  of 
daily  experience.  The  change  in  the  urine  is  subsequent  and  probably 
due  to  an  escape  by  the  kidneys  of  the  morbid  product.  Dissolved  or 
broken-up  corpuscles  cast  loose  into  the  circulation  may  easily  account 
for  the  tinting  of  the  skin  as  if  by  hfematin  ;  and  also  for  the  articular 
effusions,  presumptively  of  blood  or  blood  substance,  which  were  ob- 
served, as  if  the  blood  waste  had  sought  other  exits  beside  the  renal. 
That  the  kidneys  become  congested,  sometimes  intensely  so,  under  the 
process,  is  evinced  by  the  lumbar  pain,  the  retraction  of  the  testicles, 
and  the  other  passing  signs  of  irritation  which  they  manifest;  there  is 
even  the  suggestion  of  the  case,  to  which  I  need  not  again  recur,  that 
they  may  become  congested  to  bursting  or  fatally  inflamed  under  the 
disturbance.  But  it  is  clear  that  whatever  happens  to  the  kidneys  is 
consequent  upon  the  disorder,  not  antecedent  to  it.  The  natural  ac- 
tion of  these  organs  in  the  intervals,  and  the  post-mortem  evidence 
which  we  have,  are  suflflcient  to  show  that  their  change  of  function  is  due 
to  passing  circumstances,  not  to  permaueut  change. 

Apart  from  ha?moglobinuria  as  an  intermittent  or  paroxysmal  dis- 
order, a  similar  condition  of  urine  is  known  to  occur  as  the  consequence 
of  many  states  of  blood,  some  produced  by  disease,  others  by  matters 
artificially  introduced.  It  has  long  been  known  that  the  inhalation  of 
arseniu retted  hydrogen  produced  a  condition  of  urine  in  which  blood 
was  apparently  dissolved,  and  the  same  result  has  been  extended  to  other 
toxic  agents,  among  which  may  be  mentioned  naphtha,  benzol,  hydro- 
chloric acid,  and  chlorate  of  potash.  With  regard  to  the  latter.  Dr. 
Dreschfield  and  Mr.  Stocks  have  recorded  the  case  of  a  woman  who. 
after  taking,  in  the  course  of  twenty-four  hours,  an  ounce  and  a  half  of 
chlorate  of  potash,  passed  haemoglobin  in  the  urine,  by  vomiting,  from 
the  rectum,  and  from  the  vagina.  The  convoluted  and  straight  tubes 
of  the  kidneys  were  filled  partly  with  granules  and  partly  with  blood- 
corpuscles,  in  which  the  coloring  matter  appeared  to  be  precipitated. 
The  Malpighian  bodies  were  natural.  Blood-corpuscles  are  known  to  be 
soluble  in  water,  and  it  has  been  stated  that  the  injection  of  Avater  into 
the  veins  of  animals,  as  well  as  of  glycerin  and  water  into  the  cellular 
tissue,  have  been  followed  by  the  exit  of  dissolved  blood  with  the  urine, 
and  the  same  result  has  been  noted  in  dogs  who  have  been  subjected  to 
a  starvation  diet  of  sugar  and  water.  The  same  condition  has  been 
found  in  the  human  subject  in  connection  with  certain  septicaemic  and 
febrile  conditions,  among  which  is  typhus  ;  and  it  is  said  also  to  have 
been  found  with  scurvy  and  purpura,  though  I  may  say  that  in  my  own 
not  very  large  experience  of  the  latter  disorders  I  have  noticed  the 
blood  discharged  with  the  urine  to  retain  the  corpuscular  form.'     Thus 

'  M.  Cazeneuve,  Lyon  Med.,  1880,  p.  88.     M.  Mesnet,  Archives  Generates  de 


INTERMITTENT    HiEMATCRIA    OR    H^MO~GLOBINURIA.  289 

it  appears  that  blood-corpuscles  may  be  dissolved  within  the  body  by 
many  agents  and  in  many  circumstances,  and  the  product  make  its  way 
out  by  the  kidneys;  but  these  conditions  of  haemoglobinuria,  in  which 
the  solution  is  ostensibly  and  primarily  due  to  some  toxic  agent  in  the 
blood,  or  change  in  its  composition,  present  only  a  partial  analogy  with 
the  obscure  and  recurrent  disorder  under  consideration. 

A  closer  analogue  to  this  is  occasionally  presented  in  cases  of 
the  symmetrical  gangrene,  or  localized  asphyxia  of  Reynaud.  This 
condition  may.  concur  with  the  state  of  urine  which  has  been  under 
discussion:  and,  indeed,  the  disorder  of  Reynaud  appears  to  be  so 
closely  connected  with  intermittent  hsematuria  that  no  distinct  line  of 
demarcation  can  be  drawn  between  the  two.  The  essentials  of  Rey- 
naud's  disease  are  the  arrest  of  circulation,  with  coldness,  blueness,  and 
often  subsequent  gangrene,  in  certain  parts  often  prominent,  such  as 
lingers  or  toes,  and  often  disposed  with  bilateral  symmetry.  In  certain 
instances  and  in  certain  phases  of  this  disease  hgematuria  has  occurred 
and  recurred,  much  after  the  manner  of  the  intermittent  haemorrhage 
under  discussion,  either  with  the  escape  of  corpuscles  or  as  hasmoglobin- 
uriii.  A  boy,  whose  case  is  related  by  Dr.  Wilks,'  had,  after  protracted 
suppuration,  the  result  of  an  injury,  gangrene  of  the  fingers,  such  as  is 
described  by  Reynaud,  attended  Avith  the  discharge  of  haemoglobin  and 
casts  with  urine,  with  only  the  occasional  presence  of  corpuscles.  Dr. 
Southey  gives  the  case  of  a  lad  who  had  gangrene,  first  of  the  right  in- 
dex and  then  of  other  fingers,  while  purple  patches,  which  threatened 
to  lead  to  the  same  condition,  appeared  on  one  ear  and  the  nose.  The 
parts  about  to  become  gangrenous  first  became  red,  swollen,  throbbing, 
and  hot  like  chilblains.  The  skin  generally  was  peculiarly  sensitive  to 
cold  impressions,  becoming  on  exposure  remarkably  mottled,  while  parts 
that  were  covered  were  apt  to  become  hot  and  red,  and  throbbed  and 
burned,  so  that  he  could  no  longer  bear  anything  upon  them.  The 
mottlings  referred  to  developed  into  patches  of  urticaria,  which  pre- 
sented themselves  widely  over  the  face,  trunk,  and  limbs.  The  urine 
became  bloody  under  superficial  cold,  then,  after  exi^osure  and  being 
washed,  it  would  be  bloody;  a  few  hours  later  not  so.  Blood-corpuscles 
were  found,  but  no  casts;  the  urine  was  often  albuminous  out  of  pro- 
portion to  the  blood.  No  haemorrhages  occurred,  except  with  the  urine; 
iliere  was  no  dropsy.  In  this  case,  though  the  hgematuria  might  be 
termed  intermittent  or  j)aroxysmal,  there  was  no  evidence  of  the  corpus- 
cular destruction  which  belongs  to  what  is  termed  hemoglobinuria. 

A  case  recorded  by  Dr.  Barlow  is  more  to  this  point.  The  subject 
was  a  girl  five  years  of  age  who  had,  especially  in  cold  weather,  repeated 
attacks  of  coldness,  blueness,  and  pain  in  one  or  both  feet,  or  one  hand, 
which  lasted  several  hours,  but  did  not  proceed  to  gangrene.  Some  of 
these  attacks,  but  not  all,  Avere  attended  Avith  the  passing  of  urine, 
usually  once  only,  Avhich  had  all  the  haemoglobinuric  character.  It  was 
very  dark;  contained  no  corpuscles,  but  much  brown  granular  matter; 
gave  a  blue  reaction  with  guaiacum,  an  albuminous  clot  of  a  tenth,  and 
a  deposit  of  oxalate  of  lime.  Occasionally  under  the  attacks  the  urine 
I)ecame  lithatic,  but  not  bloody.  The  coldness  in  the  limbs  Avas  often 
preceded  by  abdominal  pain.     Dr.   BarloAv  points  out — Avhat  indeed  is 

Medeeine,  vol.  i.  1881  p.  513.  Dr.  Dreschfield  and  Mr.  Stocks,  Trans,  of  Inter- 
national Med.  Congress,  vol.  i.  p.  398.  Dr.  Sauiulby,  Birmingham  Mel.  Review, 
March,  1882,  p.  9T. 

'  Med.  Times  and  Gazette,  1879,  vol.  ii.  p.  207. 
19 


290  INTEKMITTENT    HEMATURIA    OR    H.EMO-GLOBINURIA. 

sufficiently  striking — the  resemblance  between  this  combination  of  symp- 
toms and  that  described  as  intermittent  or  paroxysmal  haemoglobinuria. 
The  condition  of  urine  may  be  the  same  in  both,  even  to  tlie  lithiasis 
which  ap])ears  to  replace  the  iieculiar  haemorrhage.  The  attacks  occur 
usually  with  the  same  irregularity  and  from  similar  causes;  in  both 
abdominal  pain,  yawning,  and  vomiting  may  mark  tlie  beginning  of  the 
attack,  and  in  both  urticaria  may  present  itself.  The  difference  may 
declare  itself  by  little  else  than  the  more  narrow  limitation,  and  the 
greater  intensity,  of  the  superficial  arrest  of  circulation  in  the  one  case 
than  in  the  other.  Indeed,  the  two  conditions  seem  so  to  approach  each 
other  and  mingle  as  to  make  it  impossible  to  make  a  distinct  demarca- 
tion between  them. 

With  the  facts  which  have  been  passed  in  detail,  it  will  now  be  possi- 
ble to  present  in  brief  retrospect  a  rational  view  of  the  intermittent 
condition  of  hfemoglobinuria.  It  occurs  independent  of  organic  disease, 
though  the  kidney  is  concerned  usually  temporarily  in  the  attacks,  but 
depends  on  a  destruction  of  blood  within  its  proper  vessels  from  causes 
which  have  to  be  considered.  The  association  of  the  disorder  with  ma- 
larial fever  and  its  sequence,  without  the  intervention  of  fever  upon 
malarial  exposure,  is  such  as  to  lead  to  the  inference  that,  at  least  in 
many  cases,  it  is  but  ague  misdirected.  With  ague  of  the  common  sort, 
we  may  presume  that  the  rigor  indicates  the  presence  of  a  poison  in 
the  blood,  which  is  presently  eliminated  by  sweating  and  the  discharge 
of  lithates  with  the  urine.  With  the  hfematuric  attack,  the  disorder 
points  renally.  The  heat  of  skin  is  not  indeed  always  absent,  but  is 
usually  little  marked,  to  be  replaced,  as  we  may  fairly  infer,  by  a  corre- 
sponding condition  of  the  kidney,  with  relief  by  renal  instead  of  cutane- 
ous evacuation.  The  frequent  mixture  of  lithates  with  haematuric  dis- 
charge, and  their  substitution  for  or  succession  upon  it,  bears  out  the 
analogy. 

The  increase  of  urea,  which  is  so  marked  under  the  ordinary  ague 
fit,  is  not  equally  so  with  that  of  hemoglobinuria:  probably  the  mate- 
rials which  should  form  the  urea  are  expended  as  haemorrhage.  Under 
paroxysms  of  ague  the  urine  has  often  been  found  to  be  albuminous, 
and  sometimes  bloody:  the  hiematuria  of  an  ague  fit  may  be  attended 
with  corpuscular  disintegration,  and  the  one  disease  may  jjass  into  the 
other,  so  that  the  two  conditions  present  themselves  but  as  phases  of 
the  same  disease. 

This  is  seen  with  the  malignant  malarial  disorder  described  as  bilious 
or  haematuric  fever,  in  which  it  is  said  that  the  urine  presents  the  hae- 
moglobinuric  characters.'  The  renal  congestion  of  the  ague  fit  is  indeed 
a  prominent  fact  in  its  pathology,  and  is  probably  the  means  by  which 
granulation  of  the  kidney  is  brought  about,  as  has  been  insisted  upon 
in  an  earlier  section  of  this  work,  by  intermittent  fever.  And  not  only 
are  the  two  disorders  associated  by  the  renal  congestion  common  to 
both,  but  it  would  seem,  from  the  anaemiating  results  of  common  inter- 
mittents,  as  well  as  from  the  diffusion  of  pigmentary  products  under 
their  influence  and  the  occasional  yellow  tinting  of  the  skin,  that  with 
them  as  with  hgemoglobinuria  there  is  extensive  destruction  of  blood 
in  its  own  vessels.  Another  point  of  resemblance  is  to  be  found  in  the 
enlargement  of  the  spleen  common  with  ordinary  ague  and  occasionally 

'  Corre,  Arch,  de  Med.,  Nov.,  1881.  Gazette  Hebdomadaire,  April,  1881,  p. 
249. 


INTERMITTENT    H.EMATURIA    OR    H^MO-GLOBINURIA.  291 

found  in  the  hsemorrhagic  disorder.  The  heaps  of  blood-pigment  found 
in  the  spleen  of  Catherine  Evans  (see  woodcut,  page  286),  are  quite 
such  as  might  have  belonged  to  malarial  disease,  with  which,  indeed, 
this  case  was  associated,  insomuch  that  it  might  have  been  termed,  with 
equal  truth,  haemoglobinuria  or  malarial  fever. 

But  the  association  with  malaria,  though  possibly  more  frequent  than 
our  records  show,  does  not  comprise  the  wdiole  history  of  the  condition. 
Cases  present  themselves  in  which  no  malarial  influence  can  be  ascer- 
tained or  suspected.  1  have  adverted  to  the  occurrence  of  hemoglobin- 
uria with  the  local  asphyxia  of  Reynaud.  We  do  not  know  enough  of 
this  condition  to  assert  that  it  is  regularly,  or  often,  of  malarial  ante- 
cedents, but  Reynaud  has  given  a  case  on  the  authority  of  Dr.  Landry, 
in  which  this  sequence  held;  and  it  must  be  noted  in  connection  with 
this  occurrence  that  gangrene  has  frequently  been  observed  in  connection 
with,  and  apj^arently  as  a  result  of  malarial  fevers.' 

Whatever  be  the  remote  cause  of  the  condition,  it  appears  that  the 
immediate  precursor  of  the  discharge  is  contraction  of  the  superficial 
arteries,  whether  in  connection  with  ague,  with  the  local  asphyxia  of 
Reynaud,  or  possibly,  independently  of  both,  as  belonging  to  an  isolated 
and  unexplained  form  of  hemoglobinuria.  We  may  accept  provi- 
sionally the  view  of  Professor  Murri  that  the  corpuscular  destruc- 
tion takes  place  in  the  superficial  vessels  in  which  the  stagnation  has 
occurred,  and  that  arterial  spasm,  whatever  be  its  cause,  is  the  essential 
factor  in  the  disease. 

These  conclusions  are  not  contradicted  by  the  exceptional  appear- 
ance of  the  disorder  after  violence,  exercise,  and  alcoholic  excess;  the  dis- 
ease has  not  been  thus  created;  the  attacks  have  been  brought  on  in  a 
person  who  has  previously  acquired  the  liability. 

As  to  treatment:  tenacious  as  the  disorder  proves  itself  in  many  cases, 
there  are  others  which  show  that,  independently  of  medicine,  it  has  a 
tendency  to  recovery.  No  patient  is  as  yet  known  to  have  died  directly 
of  the  disease,  though  many  have  died  with  it;  some  have  been  ajjpar- 
ently  cured,  and  others  have  outlived  it.  The  measures  which  are  indi- 
cated are  of  two  kinds:  quinine  as  possibly  curative  of  the  disorder; 
uniform  warmth  as  jn-eventive  of  the  attacks. 

The  most  remarkable  point  in  the  therapeutics  of  the  complaint  is 
the  effect  of  temperature.  Patients  when  attacked  instinctively  seek 
warmth;  go  to  bed  if  they  can,  cover  themselves  with  clothes,  and  await 
the  relief  which  the  warmth  brings.  In  most  instances,  cold  is  the  only 
exciting  cause  of  the  attack;  in  constant  warmth  they  are  totally  absent. 
Even  when,  as  in  the  case  of  Dr.  Druitt,  the  disorder  in  a  temperate 
climate  has  displayed  a  periodic  or  diurnal  tendency,  its  habit  in  that 
respect  has  been  completely  broken  by  a  tropical  temperature.  Dr. 
Druitt  had  but  one  attack  of  his  disorder,  and  that  brought  on  by  a 
definite  chill  during  his  winter  in  Madras.  Possibly  some  such  tropi- 
cal, or  a  subtropical,  resort,  with  quinine  if  indicated,  and  especial 
care  to  avoid  malaria,  would  be  more  often  desirable  than  attainable  in  this 
disease.  Where  not  attainable,  much  may  be  done  with  warm  clothing 
and  by  the  avoidance  of  exposure,  together  with  a  dietary,  including 
wine  or  some  alcoholic  drink,  somewhat  oftener  than  might  otherwise 
be  needed.  Such  measures  may  keep  off  the  attacks;  and  with  a  disor- 
der often  of  limited  duration,  this  may  be  equivalent  to  curing  the  dis- 

'  Hertz,  Malarial  Diseases,  Ziemssen's  Cyclopaedia,  vol.  ii.  p.  613. 


292  INTERMITTENT    H.EMATURIA    CR    H.EMO  GI.(>BINUKIA. 

ease.  Dr.  Barlow'  found  that  a  patient  of  his  wlio  from  childhood  had 
been  washed  in  very  hot  water,  became  less  susceptible  to  the  disorder 
Avhen  cold  water  had  been  gradually  substituted  for  hot:  the  suggestion 
presented  must  be  put  to  the  test  of  further  experience. 

As  to  pharmaceutical  measures,  quinine  takes  the  first  place.  Ob- 
viously suggested  by  the  aguish  similitude  and  the  occasional  aguish  an- 
tecedents of  tlie  disease,  tlie  remedy  is  no  novelty  in  this  relation.  It 
was,  as  already  stated,  employed  by  Prout.  Though  its  specific  action 
appears  to  be  less  marked  than  with  the  common  forms  of  ague,  the  facts 
which  have  been  accumulated  do  not  allow  us  to  doubt  that  something 
of  the  same  effect  must  be  attributed  to  it.  Dr.  Druitt,  who  spoke  from 
an  experience  which  probably  no  other  member  of  the  profession  can 
adduce,  says,  "of  medicines  deserving  the  name  there  was  but  one,  and 
that  was  quinine  in  full  doses."  He  found  that  the  attacks  were  kept 
off  by  large  doses  of  the  drug,  but  that  its  beneficial  effect  dimin- 
ished with  repetition,  until  at  last,  though  it  still  continued  to  be  gen- 
erally beneficial  to  health,  it  lost  its  control  over  the  hasmorrhage.  And 
many  other  cases  testify  at  least  to  the  suspension  of  the  disorder 
under  quinine,  while  with  some  it  has  totally  ceased  under  its  influ- 
ence. 

My  own  experience  amounts  to  this:  I  have  treated  seven  patients  with 
quinine  alone;  four  with  quinine  and  iron;  one  with  quinine  and  iodide  of 
potassium;  one  with  iodide  of  potassium  alone;  one  with  iron  alone;  and 
several  without  medicine.  Of  those  who  took  quinine  alone,  five  were  ob- 
viously benefited,  two  of  whom  were  apparently  cured.  In  one  the  remedy 
was  discontinued  on  the  occurrence  of  measles;  in  another,  no  definite 
result  was  obtained.  Two  considerations  make  it  difficult  to  estimate  the 
effects  of  any  remedy  in  this  disorder:  one  is  the  capricious  manner  in 
which  it  will  sometimes  come  to  an  end;  the  other  is  its  tendency  to  re- 
cur after  a  long  interval  when  thought  to  be  cured.  The  cases  most 
amenable  are  those  in  which  the  aguish  antecedents  are  most  distinct. 
The  man  whose  case  I  brought  before  the  Medico-Chirurgical  Society  in 
the  year  1865,  who  had  had  ague  fourteen  years  before  his  attack,  and*- 
was  attacked  in  an  aguish  district,  having  all  but  died  under  the  com- 
bined effects  of  mercury  and  pneumonia,  lost  his  symptoms  under  qui-' 
nine  and  iron,  left  the  hospital  apparently  well,  and  when  by  chance  I 
saw  him  four  years  later  (1869),  had  had  no  return. 

A  man  who  had  had  a  malarial  affection  three  years  before  the  hae- 
maturia,  lost  the  latter  under  quinine  and  iron,  and  three  years  later 
was  still  free.  In  five  cases  the  attacks  ceased  to  occur  under  full  doses 
of  quinine  conjoined,  in  two  of  them,  with  iron,  though  the  evidence 
of  recovery  is  inconclusive.  In  one  of  these,  the  hrematuric  symptoms 
entirely  ceased,  and  remained  absent  until  her  death,  which  was  due  to 
another  cause.  The  remaining  four  patients — Madden,  Hercock,  Tay- 
lor, and  Jones — left  the  hospital  apparently  well,  though  it  was  not 
known  how  long  they  remained  so.  Two  cases,  treated  with  quinine  alone, 
left  the  hospital  apparently  well,  but  had  recurrences  afterwards  (K. 
Baker  and  Stone).  The  quinine  to  be  effective,  whether  permanently  or 
temporarily,  needed  to  be  given  in  full  doses,  generally  about  twenty 
grains  a  day.  One  of  these,  a  child  nine  years  of  age,  had  recurrences 
under  six  grains  a  day,  none  under  nine  grains. 


'  Clin.  Trans.,  vul.  xvi.  p.  188. 


INTEKMITTENT    HiEMATURIA    OR    H^MO-GLOBINDRIA.  293 

Other  drugs  may  be  more  briefly  dismissed.  Arsenic  has  been  nsed, 
and  may  be  i;seful  as  an  antiperiodic,  should  quinine  fail  or  be  inadmis- 
sible. Antisyphilitic  measures  have  been  resorted  to,  though  we  have 
no  reason  to  suppose  that  syphilis  is  often,  or  especially,  associated  with 
the  disease.  Yet  it  may  co-exist,  and  in  two  of  my  cases  iodide  of 
potassium  was  given  with  apparent  advantage.  Professor  Murri  has 
attributed  benefit  to  mercury  in  similar  circumstances.  Apart  from 
syphilis,  mercury  proved  so  obviously  injurious  in  a  case  I  have  already 
adverted  to  that  I  have  refrained  from  employing  it.  The  yellowness  of 
the  skin  has  occasionally  directed  the  efforts  of  the  practitioner  to  the 
liver,  and  suggested  mercurials,  nitro-muriatic  acid,  and  other  reputed 
remedies  for  jaundice.  But  bile  is  not  wanting  in  the  motions;  and  if 
the  color  of  skin  is  by  blood  and  not  by  bile,  such  drugs  at  best  are 
useless.  The  action  of  this  metal  in  reducing  the  number  of  blood-cor- 
puscles and  causing  anaemia  would  seem  to  render  it  better  suited  to 
increase  than  to  diminish  the  effects  of  the  disorder. 

Of  direct  means  of  stopping  the  htemorrhage  there  are  none  except  it 
be  warmth.  Iron  is  an  obvious  requirement  to  mitigate  the  results  of 
the  haemorrhage,  and  may  be  given  in  an  astringent  form. 


I 


CHAPTER   XXI. 

OX    EXCESS    OF   THE    EARTHY    SALTS,    MORE    PARTICU- 
LARLY PHOSPHATE  OF  LIME,  IX  URIXE. 

L^XTiL  recent  years  much  confusion  attended  the  use  of  the  terms 
phosphatic  urine  and  phosphatic  diathesis ;  the  urine  was  said  to  be 
phospliatic  and  the  i^erson  to  have  tlie  phosphatic  diathesis  whenever 
the  urine  deposited  earthy  salts:  in  other  words,  whenever  it  was  alka- 
line, whether  it  had  become  so  in  the  bladder  by  ammonical  decomposi- 
tion, or  had  J)een  so  secreted  by  the  kidney  from  a  deficiency  of  acid,  or 
an  excess  of  alkali.  Urine  alkaline  from  whatever  cause  necessarily  de- 
posits its  earthy  salts,  whether  they  be  much  or  little,  and  thus  the 
jDhosphatic  diathesis  was  found  by  the  older  writers  in  a  large  number  of 
widely  different  conditions,  comprising  some  of  constitutional  disturb- 
ance, and  may  others  in  which  the  reaction  was  simply  due  to  the  state 
of  the  urinary  organs.  Urine  is  very  seldom — it  used  to  be  thought 
never — secreted  ammoniacal.  There  are  excejjtional  conditions  of  ex- 
haustion or  prostration  apart  from  any  localized  disease,  either  of  the 
nervous  or  the  urinary  systems,  in  which  it  will  at  times,  and  even  for 
a  long  time  together,  present  itself  in  an  ammoniacal  state  in  circum- 
stances which  lead  to  the  belief  that  it  has  been  so  secreted  (see  page 
145);  but  these  may  be  put  aside  as  exceptional,  and  the  general  rule 
asserted  that  its  being  passed  in  this  state  is  merely  an  evidence  of  retention 
or  cystitis.  AVith  such  various  conditions  leading  to  alkalescence  and 
deposition,  it  would  seem  impossible  without  reference  to  their  differ- 
ences to  discern  any  common  diathesis  or  systemic  state  as  antecedent  to 
the  urinary  condition.  Prout,  however,  in  whose  time  the  necessary 
distinctions  had  not  been  made,  associates  these  depositions,  however 
various  their  origin,  with  depression  and  nervous  irritability;  and  though 
it  is  clear  that  in  many  of  the  instances  to  which  he  alludes  the  urinary 
state  has  been  brought  about  only  by  disease  of  the  urinary  organs,  yet 
there  would  seem  to  be  a  partial  truth  in  his  view  which  has  escaped 
some  later  observers. 

Dr.  Hassall  attributed  grave  constitutional  symptoms  to  the  precipi- 
tation of  the  crystalline  phosphate  of  lime  ;  but  this  view  also  has  been 
shown  to  need  modification  since  this  deposit  may  be  caused  either  by 
the  increased  excretion  of  lime,  which  may  be  caused  by  the  a<lministra- 
tion  of  lime  salts,  or  by  a  diminished  acidity  of  urine  short  of  alkales- 
cence.'    Whether  the  lime  secreted  by  the  kidneys  shall  appear  in  crys- 

'  Dr.  Bence  Jones  published  in  the  Journal  of  the  Chemical  Society  for  1861 
the  results  of  some  experiments  and  observations  in  which  I  had  taken  part  hav- 
inj?  reference  to  the  deposition  in  the  urine  of  tJie  crystalUne  phosplvate  of  lime. 
The  conclusion,  which  was  inevitable,  was  that  the  formation  of  these  crystals 
simply  depends  on  the  amoiuit  of  lime  iu  the  urine  and  on  its  degree  of  acidity. 


EXCESS    OF    EARTHY    SALTS    IN    URINE.  295 

tals  as  the  acid  phosphate,  shall  be  deposited  as  the  amorphous  or  alka- 
line phosphate,  or  shall  be  held  in  solution  in  the  urine,  is  so  far  a 
matter  of  chance  that  it  depends  only  on  the  degree  of  acidity  of  the 
urine.  If  the  nrine  be  alkaline,  the  amorphous  phosphate  is  precipi- 
tated; if  it  be  slightly  acid  or  nearly  neutral,  the  crystalline  phosphate 
appears;  while,  however  great  the  amount  of  lime  if  the  urine  be  fully 
acid,  there  is  no  deposit  whatever,  or  a  deposit  only  of  oxalate.  No  in- 
ference, therefore,  save  as  to  the  acidity  of  the  urine,  can  be  drawn 
from  the  shape  which  the  earthy  salts  take  in  that  secretion. 

But  while,  therefore,  we  regard  the  shape  which  the  earthy  salts 
take  as  only  of  secondary  importance,  I  think  that  clinical  evidence,  to  a 
certain  extent  corroborating  Prout  and  Hassall,  shows  that  the  absolute 
excretion  of  lime,  or  the  amount  passed  be  the  shape  what  it  may,  has 
an  important  significance  as  bearing  upon  the  constitutional  state,  more 
particularly  with  reference  to  the  nervous  system. 

In  common  with  what  I  believe  is  a  very  general  impression,  I  have 
learned  to  recognize  a  certain  condition  of  nervous  irritation  or  exhaus- 
tion, or  a  habitual  state  of  exaggerated  nervous  mobility,  as  associated 
with  urine  of  which  the  leading  characteristic  is  an  excess  of  earthy 
salts.  Such  urine  may  be  alkaline  and  turbid,  but  is  usually  pale  and 
clear;  its  tints  incline  rather  to  lemon  than  orange;  lithates,  if  deposited, 
are  pale  or  white;  it  is  but  rarely  of  insufficient  acidity,  and  sometimes 
is  acid  to  excess,  even  to  scalding.  Excepting  occasional  lithates,  it  is 
usually  free  from  deposit,  or  deposits  only  oxalate  of  lime.  The  addi- 
tion of  liquor  potassffi  or  ammonia,  however,  throws  down  a  heavy  cloud, 
which  consists  chiefly  of  phosphate  of  lime.  The  persons  who  have 
passed  such  urine  have  mostly  t)een  men  not  far  removed  from  middle 
life,  usually  of  active  minds  and  nervous  temperaments,  easily  agitated 
or  depressed,  tremulous,  excitable,  and  prone  to  sleeplessness.  Many 
have  had  obscure  arthritic  pains  which  have  been  regarded  as  gouty,  but 
few  gout  in  a  sthenic  and  declared  form.  The  characters  of  the  urine 
became  more  marked,  and  in  some  instances  first  attracted  my  attention, 
after  some  period  of  anxiety  or  mental  distress. 

A  symptom  to  be  often  noted  in  such  persons  as  I  have  described  is 
a  somewhat  indefinite  numbness  in  the  legs  which  comes  and  goes  ; 
others  have  complained  of  singing,  dizziness,  or  other  abnormal  sensa- 
tions in  the  head.  The  tongue  is  usually  anasmic,  flabby,  and  sodden  ; 
it  becomes  more  coated  under  salines  or  alkalies,  and  clear  with  strych- 
nia and  nitro-hydrochloric  acid.  There  is  intolerance  of  alkalies  in 
these  cases,  for  whatever  cause  they  may  be  given,  displayed  by  general 
prostration  and  early  alkalinity  of  urine.  Strychnia  and  the  mineral 
acids,  on  the  other  hand,  are  as  constantly  beneficial. 

Instances  of  an  excess  of  the  earthy  salts,  particularly  of  the  phosphate 
of  lime,  in  such  circumstances  as  I  have  mentioned  might  be  greatly 
multiplied.  I  have  learned  to  recognize  the  manner  of  man  in  whom  it 
exists,  and  seldom  look  for  it  in  vain.  The  nervous,  mobile,  and  hypo- 
chondriacal temperament,  with  perhaps  half-latent  gout,  suggests  the 
testing  of  the  urine  with  liquor  potassa?,  and  the  fall  of  the  bulky  pre- 
cipitate no  less  suggests  the  use  of  strychnia  and  the  mineral  acids.  Ex- 
amples, some  of  which  have  been  already  alluded  to,  which  show   the 

They  could  be  generally  caused  by  the  administration  of  lime  or  its  vegetable 
salts  until  the  urine  became  charged  with  lime  while  its  acidity  was  lessened. 
Dr.  Roberts  independently  had  arrived  at  similar  conclusions. 


296 


EXCESS    OF    EARTHY    SALTS    IN    URINE. 


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298  EXCESS    OF    EARTHY    SALTS    IN    URINE. 

amount  of  tlie  earths  passed  in  twenty-four  hours,  or  where  this  was  not 
possil)le  in  100  parts  of  urine,  are  subjoined  in  a  tabular  form,  [See  p. 
296.] 

Tlie  only  one  of  the  tabulated  cases  which  needs  further  mention  is 
the  last  of  the  first  series.  It  was  remarkable  in  the  habitual  presence 
of  profuse  alkaline  sweat  which  was  poured  out  abundantly,  particularly 
under  the  arms,  even  though  the  patient  kept  cold  and  perfectly  still. 
The  secretion  was  alkaline  from  fixed  alkali.  It  increased  with  depres- 
sion or  exhaustion,  and  lessened  with  rest,  good  diet,  and  tonics.  Both 
lime  and  magnesia  must  be  considered  as  increased,  considering  the  age 
of  the  patient. 

To  take  a  somewhat  wider  view  of  the  urinary  secretion  of  lime  and 
magnesia,  I  have  subjoined  a  few  observations  in  reference  to  other  dis- 
orders, from  whence  it  appears  that  in  instances  of  tubercular  disease  of 
the  brain,  tubercular  meningitis,  epilepsy,  and  cerebral  amaurosis,  the 
exit  of  lime  was  increased.  'J'o  the  foregoing  facts  may  be  added  that  in 
some  cases  of  diabetes,  especially  the  most  acute,  there  is,  perhaps,  a 
larger  increase  of  phosphate  of  lime  than  occurs  in  any  other  circum- 
stances. The  woman  Mackay  passed  as  much  of  the  salt  in  one  day  as 
she  should  have  passed  in  ten;  more  than  three  grammes  of  lime,  or 
about  six  of  the  phosphate.  This  salt  was  increased  out  of  proportion 
to  the  urine,  and  in  larger  ratio  than  any  other  of  its  constituents.  The 
condition  was  associated  with  cerebral  changes  of  unusual  extent  and 
rapidity.  In  another  rapid  and  severe  case  was  nearly  as  great  an  increase 
of  the  earth  in  question.  It  is  noteworthy  that  this  enormous  increase 
of  lime  was  not  dependent  on  any  increase  of  food;  but,  on  the  contrary, 
was  most  marked  when  the  disorder  was  approaching  its  fatal  termina- 
tion, the  power  of  taking  food  almost  lost,  and  the  urine  no  longer  sac- 
charine, or  but  slightly  so. 

Observations  on  the  excretion  of  phosphates  in  disease  were  made  by 
Bence  Jones  as  long  ago  as  184G. '  The  most  marked  result  of  his  in- 
quiry was  the  contrast  in  this  respect  between  inflammatory  affections  of 
the  brain  and  delirium  tremens;  in  the  former,  meningitis  and  the  like, 
both  the  total  i^hosphoric  acid  and  the  earthy  phosphates  being  much 
increased,  in  delirium  tremens  both  being  as  strikingly  diminished. 
According  to  the  view  of  Bence  Jones,  the  phosphorus  which  so  largely 
enters  into  the  composition  of  the  brain  undergoes  under  inflammation  in- 
creased oxidation,  with  a  correspondingly  increased  production  and  exit 
of  phosphoric  acid.  The  lessened  discharge  of  this  acid  in  delirium 
tremens  was  no  doubt  partially  due  to  absence  of  food,  but  it  was  shown 
that  it  could  not  wholly  be  thus  accounted  for,  and  might  with  ])rob- 
ability  be  attributed  to  lessened  chemical  action  in  a  brain  of  which  the 
condition  was  the  opposite  of  the  inflammatory. 

About  a  third  of  the  phosphoric  acid  which  is  normally  passed  with 
the  urine  is  in  combination  with  lime  and  magnesia,  the  rest  with  potash 
and  soda.  It  is  not  my  purpose  to  dwell  upon  the  variations  of  phos- 
phoric acid  in  disease,  which  have  received  full  attention,  but  rather  to  re- 
fer to  those  of  the  earths  which  are  more  striking,  and  appear  more 
indicative  than  any  alterations  in  the  urinary  phosphoric  acid  taken  as  a 
whole. 

For  purposes  of  chemical  estimation,  it  may  be  assumed  that  the 
earths  occur  in  the  urine  wholly  as  phosphates;  lithate  of  lime  is  a  rar- 


LMed.  Chir.  Trans,  for  1847. 


EXCESS    OF    EARTHY    SALTS    IN    UKINE.  299 

ity;  and  the  oxalate,  however  frequent,  does  not  attain  an  amount  to  be 
appreciable  save  with  the  microscope.  The  amount  of  earthy  phosphates 
can  be  judged  of  either  by  ascertaining  the  amounts  of  lime  and  magne- 
sia separately,  the  more  laborious  process,  but  as  distinguishing  the 
earths  the  more  instructive,  or  by  precipitating  both  together  as  phos- 
phates. A  rough  but  trustworthy  bedside  guide,  if  the  urine  be  clear, 
is  the  bulk  of  the  precipitate  presented  to  the  eye  on  the  addition  of 
liquor  potassae  or  ammonia.  Perhaps  it  is  more  to  the  purpose  to  associ- 
ate the  earthy  excess  clinically  with  conditions  of  nervous  irritation,  than 
to  speculate  on  the  internal  chemistry  by  which  the  discharge  is  produced. 
"What  lime  can  have  to  do  with  brain  is  hard  to  see;  it  enters  most  spar- 
ingly into  its  composition,  and  can  scarcely  be  an  appreciable  product 
of  its  waste;  phosphorus,  on  the  other  hand,  abounds  in  nervous  tissue, 
and  under  disintegration  or  change  may  be  a  copious  source  of  phosphoric 
acid.  And  this  poured  into  the  blood,  the  conversion  of  much  of  it  into 
phosphate  of  lime,  and  its  exit  in  this  shape,  is  what  may  be  reckoned 
upon  having  regard  to  the  affinities  of  the  acid  and  the  base.  Against 
this  view  we  have  the  lack  of  evidence  that  the  phosphoric  acid  is  in- 
creased otherwise  than  in  earthy  combination,  and  also  the  minute  but 
at  least  suggestive  appearance  of  lime  in  other  forms  than  as  phosphate. 
Whatever  be  the  explanation  of  the  facts  which  have  been  noted,  it  is 
clear  as  a  matter  of  clinical  experience  that  an  increased  discharge  of 
earthy  salts  in  the  urine  appears  in  connection  with  many  forms  of  ner- 
vous irritation,  and  affords  in  some  circumstances  a  ready  and  valuable 
therapeutical  guide. 


CHAPTER    XXII. 

ALBUMINURIA   GENERALLY    CONSIDERED    IX   RELATION 
TO   RENAL   AND   OTHER  DISORDERS. 

Ukine  may  be  secreted  albuminous,  or  may  be  made  so,  since  its 
secretion,  by  admixture  with  some  albuminous  product.  To  dispose,  in_ 
the  first  place,  of  what  may  be  termed  accidental  albuminuria:  this  may 
be  due  to  the  intrusion  of  blood,  pus,  or  chyle.  It  was  formerly  thought 
that  the  spermatic  fluid  could  produce  this  effect,  but  now  stated  that 
semen  is  not  albuminous.  These  vehicles  of  albumin  are  easily  recog- 
nized by  their  obvious  and  microscopic  characters  ;  the  only  doubts 
which  ever  need  present  themselves  are,  supposing  the  urine  to  contain 
blood  or  pus,  whether  the  albumin  is  wholly  or  only  in  part  due  to 
this  cause. 

It  is  not  my  design  to  dwell  at  length  upon  the  means  of  testing  for 
albumin,  some  of  which  have  occupied  much  attention  of  late.'  "When- 
ever the  urine  is  described  as  albuminous  in  this  work,  it  is  upon  the 
evidence  of  heat  and  nitric  acid.  I  examined  for  albumin  by  five 
methods  the  urine  of  100  patients,  as  they  presented  themselves  consecu- 
tively in  hospital  and  private  practice.  The  results  which  are  given  in 
the  annexed  table  are  scarcely  calculated  to  make  us  abandon  the  old 
tests  for  the  new.  The  potassium  mercuric  iodide  gave  a  precipitate  in 
every  instance,  including  many  in  which  there  was  no  reason  to  doubt 
that  the  urine  was  absolutely  natural.  Picric  acid  was  the  next  frequent 
in  result.  It  is  known  that  both  these  reagents  precipitate  other  mat- 
ters besides  albumin,  more  particularly  the  peptones.  Whether  urine 
always  or  almost  always  contains  a  substance  analogous  to  albumin,  which 
is  not  true  serum  albumin,  niust  be  determined  by  further  inquiry.  Dr. 
Greeve  has  published  some  interesting  researches,  from  which  he  concludes 
that  healthy  urine  contains  an  albuminoid  substance  which  he  calls  leth-al- 
bumin,^  a  modification  of  albumin  not  recognizable  by  ordinary  tests. 
Whether  this  be  so  or  not,  it  is  certain  that  a  slight  precipitate  or  opa- 
lescence with  the  mercuric  iodide  is  not  necessarily  a  sign  of  disease, 
and  that  the  test  cannot  be  accepted  as  a  practical  guide.  Probably 
nitric  acid  and  heat,  used  so  as  to  be  mutually  corrective,  and  the  ferro- 
cyanide  with  citric  acid  are  the  best  tests  for  practical  use.  Picric  acid 
and  the  mercuric  iodide  are  not  sufficiently  discriminating. 

The  reactions  of  albuminous  urine  with  the  precipitants  of  albumin, 
apart  from  the  peculiarities  which  depend  upon  its  occurrence  in  acid 
or  alkaline  urine,  are  liable  to  variations  whiqh  appear  to  be  explicable 
only  on  the  supposition  that  there  are  differences  in  the  albumin.  Prout 
describes  chylous  urine  as  containing  a  substance  which  was  coagulable 

'  See  Bedside  Urine  Testing,  by  Dr.  Oliver,  of  Harrogate. 

'  Leth-Albuinin,  by  John  Greeve,  Brit.  Med.  Journ.,  May,  1879,  p.  696. 


ALBUMINURIA    IN    RELATION    TO    OTHER    DISORDERS. 


301 


Urine  from  100   Cases  taken  consecutively  from  Hospital  and  Private 
Practice  tested  for  Albumin  hy  several  Methods.^ 


Cases. 


Albuminuria  from  disease  of  kidneys 

Convalescent  t'roni  nephritis    

Stone  in  kidney , 

Disease  of  bladder  or  prostate 

Diabetes  mellitus 

Diabetes  insipidus 

Excess  of  uric  acid  or  urates 

Excess  of  phosphates ', 

Intermittent  hsematuria 

Organic  disease  of  nervous  system,  tumor  of  brain. 

locomotor  ataxy 

Functional  nervous  disease,  epilepsy,  chorea,  tinnitus. 

Nervous  debility 

Valvular  disease  of  heart  and  aneurism 

Tubercular  disease  of  lungs,  peritoneum,  etc 

Pneumonia  and  broncho-pneumonia 

Bronchitis 

Fluid  in  pleura 

Typhoid 

Measles    

Tonsillitis. ...  

Convalescent  from  acute  febrile  affections 

Disease  of  liver 

Ulcer  of  stomach 

Diarrhoea 

Enteralgia 

Peritonitis 

Rheumatism,  sciatica,  muscular  pain 

Eczema 

Anaemia  and  amenorrhcea 


100 


39 


54 


41    100 


45 


by  acid,  but  not  by  heat,  which  he  regarded  as  hydrated  or  incipient  al- 
bumin. I  suppose  it  would  now  be  called  paralbumin.  Presuming  the 
urine  to  be  acid,  this  reaction  must  be  exceptional  even  in  chylous  urine. 
A  peculiar  albuminoid  substance  was  discovered  by  Bence  Jones'^  in  the 


'  When  the  urine  of  the  .«?anie  case  has  been  examined  repeatedly,  the  first  ob- 
sei'vation  alone  has  been  tabulated.  No  examination  was  made  without  finding 
a  precipitate  or  opalescence  witii  the  potassium  mercuric  iodide. 

^  A  substance  resembling  albumin,  which  Bence  Jones  regarded  as  a  hydrated 
deutoxide  of  protein,  was  discovered  in  the  urine  of  a  patient  who  had  mollities 
ossium.  This  substance  was  discharged  in  large  amount — twice  that  of  the  urea 
— the  urine  was  acid,  of  verj-  high  specific  gravity — 1.085  to  1.040 — frothy  and  glu- 
tinous. Heated  to  boiling,  it  gave  a  precipitate  like  albumin;  with  nitric  acid, 
however,  in  the  cold,  no  immediate  precipitation  took  place,  though  after  a  time 
the  urine  became  converted  into  a  yellow,  transparent  mass,  which,  like  gelatin, 
was  dissolved  by  heat  and  again  consolidated  on  cooling.    Though  some  degx'ee  of 


302  ALBUMINURIA    IN    RELATION    TO    OTHER    DISORDERS. 

urine  of  a  patient  who  had  mollities  ossium.  On  the  addition  of  nitric 
acid,  no  change  was  at  once  produced;  on  standing,  the  urine  became 
solid;  with  heat  it  resumed  its  liquidity. 

With  regard  to  the  reaction  of  albumin  and  nitric  acid,  it  was  long 
ago  pointed  out  by  Bence  Jones  that  the  addition  of  a  minute  quantity 
of  this  acid  to  albuminous  urine  will  often  prevent  its  giving  a  coagu- 
lum  with  heat,  though  it  will  still  coagulate  on  the  addition  of  more  acid. 
This  he  supposed  was  owing  to  the  formation  of  a  nitrate  of  albumin, 
coagulable  by  acid,  but  not  by  heat.  This  reaction  appears  to  present 
considerable  variation  in  the  proportion  of  acid  needed,  and  to  be  not 
always  obtainable.  Next,  it  is  to  be  recognized  that  albumin  is  soluble 
in  excess  of  nitric  acid,  and  that  this  solubility  differs  greatly  in  dilfer- 
ent  specimens.  An  albuminous  cloud  produced  by  acid  will  often  dis- 
appear on  the  addition  of  only  a  few  drops  too  much,  while  a  bulky  co- 
agulum,  produced  by  acid  or  heat,  will  disappear  with  excess  of  acid,  the 
amount  required  for  this  re-solution  being  liable  to  great  variation. 
Sometimes  an  amount  of  acid  equal  to  that  of  the  urine  will  do;  more 
often  three  or  four  tinaes  the  bulk  is  needed. 

A  gentleman  who  recently  died  with  albuminuria,  presumably  de- 
pendent on  the  granular  kidney,  habitually  passed  alkaline  urine,  which 
with  heat  and  one  drop  of  nitric  acid  in  an  ordinary  test  tube,  coagu- 
lated to  about  a  fifth.  Three  or  four  drops  reduced  this  to  a  mere 
opalescence ;  five  or  six  made  the  urine  clear.  I  may  add  that  this 
urine,  when  it  chanced  to  be  acid,  displayed  abundance  of  casts,  and 
that  it  gave  evidence  of  globulin  with  sulphate  of  magnesia.  Albumin 
precipitated  by  acid  is  generally  more  soluble  in  excess  of  it  than  that 
thrown  down  by  heat.  The  albumin  of  lardaceous  disease  is  often  more 
soluble  than  that  which  presents  itself  in  other  forms  of  albuminuria, 
and  it  has  been  occasionally  noticed  that  the  clot  produced  with  hsemo- 
globinuria  is  re-soluble  in  more  than  ordinary  proportion,  and  the  pecu- 
liarity in  this  instance  attributed  to  admixture  with  globulin. 

We  probably  have  much  to  learn  with  regard  to  the  behavior  of 
albumin  and  its  allies  in  different  circumstances.  Such  differences  as 
have  been  adverted  to,  together  with  the  occasional  slowness  with  which 
nictric  acid  causes  coagulation,  have  given  use  to  the  term,  peculiar 
albumin/  to  signify  albumin  which  is  less  coagulable  or  more  soluble 
than  common.  Some  of  the  phases  of  incoagulability  may  be  supposed 
to  indicate  an  approach  to  the  peptones. 

I  do  not  propose  to  dwell  upon  the  subject  of  peptone  in  urine,  of 
which  both  the  chemical  and  clinical  relations  are  as  yet  imperfectly 
understood.  Peptone  'is  not  precipitated  by  heat  or  nitric  acid,  and  so 
does  not  complicate  the  subject  of  albuminuria  if  only  these  tests  be 
used;  but  it  is  thrown  down  by  picric  and  citric  acid,  and  also  by  the 
potassium  mercuric  iodide  together  with  citric  acid.  The  formation  of 
a  precipitate  with  these  reagents,  particularly  with  the  mercuric  test 
when  the  older  means  of  discovering  albumin  give  no  result,  is  so  com- 
mon, that  the  presence  of  something  which  acts  like  peptone  in  this 


oedema  was  present  in  this  case,  the  kidneys  were  found  to  be  natural  after  death, 
so  that  we  can  but  attribute  the  peculiar  discharge  to  some  condition  of  blood 
connected  with  the  softening  and  wasting  of  the  bones. 

Case  of  Mollities  and  Fragilitas  Ossium,  by  W.  Macintyre,  M.D  Med.-Chir. 
Trans  for  1850.     Also  paper  by  Dr.  Bence  Jones  in  Phil.  Trans.,  for  1848. 

'  See  Dr.  Haddon  on  Peculiar  Albumin.  Brit.  Med.  Jour.,  1876,  Part  i.,  pp. 
191,  256,  286,  and  381. 


ALBUMINURIA    IN    KELATON    TO    OTHER    DISORDERS.  303 

respect  must  be  the  rule  rather  than  the  exception.  But  it  is  probably 
not  peptone,  but  rather  something  else  allied  to  albumin  not  yet  identi- 
fied, for  it  is  often  present  in  considerable  quantity  when  the  copper 
test  gives  no  result.  Peptonuria,  as  recognized  chiefly  by  the  latter 
test,  appears  to  be  comparatively  infrequent,  and  to  have  scarcely  as  vet 
acquired  practical  interest.  It  has  been  found  in  a  variety  of  disorders 
not  especially  renal  or  attended  with  albuminuria,  among  which  phos- 
phorus poisoning,  suppurative  conditions,  and  gastric  and'intestinal  dis- 
turbances have  been  mentioned. 

The  presence  of  globulin,  or  rather  paraglobulin,  in  urine  has  more 
to  do  with  albuminuria  than  has  that  of  peptone.  I'he  occurrence  of 
this  substance  together  with  the  other  constituents  of  blood  in  hemo- 
globinuria has  no  separate  interest.  The  amount  of  it  may  be  easily 
estimated  by  precipitation  with  sulphate  of  magnesia.'  It  would  seem 
that  paraglobulin  is  almost  never  present  in  urine  except  it  be  also  albu- 
minous, and  that  when  it  is  so,  unless  it  be  also  bloody,  this  addition 
is  found  only  exceptionally  or  only  in  very  minute  amount.  Para- 
globulin is  not  soluble  in  pure  water,  though  it  is  so  in  weak  saline  solu- 
tions. Dr.  Roberts  has  recently  pointed  out  tliat  a  drop  of  albuminous 
urine  allowed  to  fall  into  a  glass  of  distilled  or  even  ordinary  drinking 
water,  a  delicate  ring  of  opacity,  like  a  puff  of  smoke,  will  often  accom- 
pany its  descent.  This  he  attributes  to  the  paraglobulin  separated  from 
the  albumin  by  its  insolubility.  This  reaction  is  often  to  be  found 
when  globulin  is  not  to  be  detected  with  sulphate  of  magnesia,  and  it 
must  still  remain  suh  judice  upon  what  it  depends. 

This  constituent  of  the  blood  appears  to  have  been  found  in  urine 
more  frequently  with  the  acute  and  the  lardaceous  forms  of  renal  disease 
than  with  others.  A  fatal  instance  of  acute  nephritis  with  dropsy  has 
been  described,  in  which  the  urine  contained  globulin,  to  the  entire  ex- 
clusion of  serum  albumin.     Casts  were  present  as  in  ordinary  cases. ^ 

Speaking  of  albumin  as  something  which  is  to  be  detected  with  heat 
and  nitric  acid,  it  may  be  said  that  urine  which  is  secreted  albuminous 
is  to  that  extent  abnormal.  The  arrangement  is  faulty  either  in  the 
renal  mechanism,  or  in  the  composition  of  the  blood,  or  in  the  pressure 
to  which  it  is  subjected.  Whether  a  minute  trace  of  albumin,  such  as 
to  be  inappreciable  to  most  tests,  may  consist  with  health,  or  whether 
healthy  urine  contains  traces  of  an  albuminoid  substance,  possibly  occu- 
pying a  position  between  albumin  and  urea,  are  questions  which  must 
be  postponed;  but,  at  any  rate,  it  is  certain  that  any  such  considerable 
admixture  of  albumin  as  to  be  readily  detected  with  heat  and  nitric  acid 
is  evidence  of  disease,  whether  permanent  or  temporary. 

Albuminuria  has  been  divided  into  permanent  and  temporary,  and 
many  observations  have  been  made  to  show  in  what  proportion  of  persons 
one  sort  or  the  other  exists,  and  with  what  disorders  they  are  associated. 
Thus,  of  303  adults  in  the  medical  wards  of  University  College  Hospital, 
39  had,  according  to  Dr.  Parkes,  ])ermanent,  and  37  temporary,  albu- 
minuria, while  in  the  remaining  'Z'Zl  cases  no  albumin  was  present  at 


'  Dr.  Marcet  reminds  me  of  the  reactions  of  globulin  as  obtained  from  the  crys- 
talline lens.  It  is  precipitated  by  carbonic  acid;  soluble  in  ammonia;  precipi- 
tated from  the  ammoniacal  solution  when  this  is  neutralized  with  acetic  acid  ; 
redissolved  in  excess  of  acetic  acid. 

^  Lancet,  1883,  vol  ii.  p.  1001.     Dr.  Womer,  of  Heidelberg. 


304  ALBUMINURIA    IN    RELATION    TO    OTHER    DISORDERS. 

any  time.  Thus  the  proportion  of  albuminuria,  passing  or  lasting,  was 
almost  exactly  one  in  four.' 

Dr.  Saundby  examined  the  urine  of  145  male  out-patients  at  the 
General  Hospital,  Birmingham,  and  found  albumin  in  105.^  In  64  the 
albumin  was  attributed  to  renal  disease.  Deducting  these,  there  remain 
81  cases  of  non-renal  disease — dyspepsia,  debility,  phthisis,  morbus  cor- 
dis, etc.,  among  which  the  urine  was  albuminous  in  41,  or  about  half. 
I  have  already  stated  the  proportion  of  albuminuria  in  patients  taken  in- 
discriminately from  hospital  and  ]u-iYate  practice  as  deduced  by  different 
tests  (p.  301).  Of  the  100  cases  referred  to,  19  were  of  kidney  disease, 
necessarily  attended  with  albuminuria  :  of  the  remaining  81,  the  urine 
showed  albumin  to  heat,  and  nitric  acid  in  21,  about  one  case  in  four. 
It  is  seen  with  sufficient  clearness  in  the  table  how  much  the  results 
differ  with  different  reagents.  Dr.  Mahomed  found  albumin  to  be  pres- 
ent in  the  urine  of  persons  proposed  for  life  assurance  in  a  proportion 
of  15.5  per  cent.  Dr.  Mann^  in  the  same  circumstances  found  albumin 
in  11  per  cent.  With  our  present  knowledge  we  must  believe  that,  how- 
ever slight  or  transient  a  disturbance  may  make  the  urine  albuminous, 
this  condition,  as  it  is  ordinarily  recognized,  is  not  consistent  with  abso- 
lute health. 

The  causes  of  albuminuria  afford  a  more  convenient  basis  of  classifica- 
tion than  its  persistence.  Urine  which,  independently  of  admixture,  is 
persistently  albuminous  indicates  a  persistent  change  in  the  kidney, 
wliether  arising  in  it  or  secondary  to  disease  elsewhere  ;  but,  on  the  other 
hand,  it  is  possible  that,  though  such  disease  exist,  the  urine  may  be  al- 
buminous only  at  times.  Thus  no  safe  distinction  can  be  made  between 
permanent  and  temporary  albuminuria. 

To  bring  within  a  simple  classification  the  various  circumstances 
upon  which  an  albuminous  state  of  the  urine  may  depend,  they  may  be 
arranged  into  three  great  classes :  the  first  may  be  termed  accidental 
albuminuria,  or  albuminuria  by  admixture,  in  which  the  secretion  has 
been  rendered  albuminous  subsequently  to  its  secretion  ;  the  second  com- 
prises the  many  modes  in  which  the  urine  may  be  made  albuminous  by 
renal  disturbance,  whether  connected  with  structural  change  or  circula- 
tory embarrassment ;  the  third  includes  those  rare  instances  in  which  the 
kidneys  secrete  albumen  in  consequence  of  an  altered  condition  of  the 
blood  "itself .  In  the  accompanying  table  all  the  subdivisions  except  the 
first  and  last  presumably  belong  to  the  second  class. 

Causes  of  an  Albuminous  State  of  the  Urine. 

Admixture  with  blood,  lymph,  chyle,  pus,  or  the  contents  of  cysts 
opening  into  the  urinary  channels,  or  with  products  derived  from  the 
bladder  or  tissues  after  death. 

Independently  of  such  admixtures,  urine  maybe  albuminous  from  : — 

f  Nephritis,  tubal  or  diffuse. 
„  ,    ,.  f  fi     I  Granular  degenenition  of  kidney,  or  interstitial  ne- 

otVnCtn  1*3,1     U.1SG3.SGS    01    tnG  J         viln-itic 

-'  I  Lardaceous  disease  of  kidnej-. 

[Abscesses  in  kidney,  pyeemic  or  uriseptic. 

'  Parkes  on  the  Urine,  p.  187. 

■  Di-.  Sauudbv,  on  the  Diagnostic  Value  of  Albuminuria.  Brit.  Med.  Jour,, 
1879.  vol.  i.  p.  G99. 

2  Quoted  by  Dr.  Middleton.     Discussion  on  Albuminuria,  Glasgow,  p.  122. 


ALBUMINUBIA    IN    RELATION    TO    OTHER    DISORDERS.  305 

f  Embolism. 
I  Thrombosis. 

^,       ^       ,    ,.  -  ,v     I  Tubercular  disease  of  kidney. 

Structural  diseases  of  thel  Cancer  or  other  growths  in  kidney, 
kidney  |  Qygtic  disease  of  kidney. 

I  Dilatation  of  kidney  from  present  or  past  obstruc- 
ts    tion. 

f  Pregnancy,  with  consequent  renal  congestion. 
Disease  of  heart  "  "  " 

r<  f         f  ir'H         irn      I  Obstruction  to  renal  circulation  by  other  mechanical 

Congestion  ot  Kianey  irom,      causes,  tumors,  etc.,  pressing  on  emulgent  veins 
mechanical  causes  ^,      or  venk  cava. 

I  Dyspncea  from  croup,  laryngitis,  bronchitis,  etc. 
[  Respiratory  embarrassment  of  epilepsy. 

r  Exposure  of  surface  to  cold,  as  in  bathing. 
^i.1  4.-        ^..^      Ague  fit. 

Other   causes,    actmg  P^e- J  Venous  congestion  of  the  dying  ? 

sumably  by  way  of  renal^  Generally  increased  vascular  tension  from  state  of 
congestion  j      blood? 

Is  Masturbation. 

„    .  •     -i.     ^  <  Cantharides,  arsenic,  phosphorus,  lead,  silver,  mer- 

Extraneous  irritants  j     ^^^^  ^,^^  ^^^^ 

("Bile  in  cases  of  jaundice,  sugar  with  diabetes. 
.       .  J  With  stone  the  urine  may  be  slightly  or  temporarily 

inherent  u-ritants  <      albuminous,  though  there  be  no  disease  of  the 

[     kidney  itself. 

„       .„    ,  ( Scarlatina,  diphtheria,  typhus,  typhoid,  erysipelas, 

Specific  fevers  |     g^.^y  p^^^  measles,  etc. 

Pneumonia. 

Cholera  and  diarrhoea. 

{Certain  nervous  conditions — injury  of  brain  and 
state  connected  with  exophthalmic  goitre— pre- 
sumably affecting  renal  blood-vessels. 

'Large  ingestion  of  albumin. 

Dyspepsia?  ?  ? 

Destruction  of  blood-corpuscles,  as  in  intermittent 

~,  J!  ui     J  •  hsematuria. 

Changes  of  blood  irrespec- ,  p^j-pm-^ 

tive  of  renal  disturbance,  j  gQ^r  w 

Various  septic  and  febrile  conditions. 
I  A  state  of  blood  connected  with  certain  conditions 
(s     of  the  liver. 

Albuminuria,  so  far  as  it  relates  to  renal  changes,  has  been  fully  dis- 
cussed. Casts  often  throw  liglit  upon  the  source  of  albumin.  If  these 
contain  blood,  or,  as  with  intermittent  haematuria,  its  substance,  it  is 
obvious  that  the  glandular  structure  gives  exit  to  the  discharge,  though 
it  may  remain  to  be  determined  whether  local  congestion  or  humoral 
change  is  the  cause.  If  epithelial,  they  indicate  tubal  disturbances  and 
an  organic  reason,  though  possibly  only  of  a  transient  kind,  for  the  albu- 
minous discharge  ;  if  merely  fibrinous,  they  show  at  least  that  not  albu- 
min only,  as  if  that  substance  were  in  excess,  but  the  liquor  sanguinis 
in  toto  is  making  its  way  out  by  reason  probably  of  local  hyperemia  or 
structural  change.  But  while  casts  as  a  rule  show  that  the  issue  of  the 
albumin  depends  upon  some  change  in  the  structure  of  the  kidney  or  in 
the  tension  of  its  vessels,  it  is  not  to  be  concluded  from  their  occasional 
20 


306  ALBUMINUKA    IX    RKI.ATION    TO    OTHER    DISORDERS. 

absence  that  it  is  not  so.  In  the  early  stages  of  the  granular  kidney  casts 
are  often  as  infrequent  as  in  tlie  early  stages  of  nephritis  they  are  abun- 
dant. The  evidence  afforded  by  the  presence  of  casts  is  therefore  more 
to  be  relied  upon  than  any  inferences  to  be  drawn  from  their  absence. 
"Witli  embolism  and  renal  pyasmia  easts  are  usually  to  be  found,  often 
Avith  blood  ;  with  tubercular  disease  of  the  kidney,  though  casts  are  not 
necessarily  present,  yet  they  are  often  to  be  found  in  consequence  of 
some  localized  tubal  disturbance  in  the  affected  organ  or  secondary  lar- 
daceous  change  in  the  other.  "With  renal  stone  a  few  casts  are  occa- 
sionally found,  probably  from  localized  irritation,  though  it  may  be 
practically  certain  that  there  is  no  general  disease  of  the  kidney  substance. 

As  to  whether  albumin  be  the  result  of  mechanical  congestion  as  from 
heart  disease  or  of  some  disorder  particular  to  the  kidney,  the  distinc- 
tion may  often  be  made  at  a  glance  ;  with  cardiac  congestion  the  urine 
is  apt  to  be  scanty  and  loaded  with  lithates  ;  with  disorders  primarily 
renal,  the  urine  however  scanty  is  only  exceptionally  lithatic. 

In  distinguishing  the  structural  diseases  of  the  kidney  from  each 
other,  the  albumin  is  often  a  guide  in  its  mode  of  accession  ;  with  ne- 
phritis it  becomes  early  large,  to  decline  gradually  with  disease  ;  with 
the  granulating  kidney  it  is  at  first,  and  often  for  long,  slight,  or  inter- 
mittent, in  the  later  stages  sometimes  little  and  sometimes  much  ;  with 
the  lardaceous  it  is  early  in  minute  quantity,  latterly  abundant. 

There  are  few  structural  diseases  of  the  kidney  which  are  not  apt  to 
make  the  urine  albuminous,  though  they  may  not  do  so  of  necessity. 
Albumin  appears  with  renal  embolism,  and  also  when  the  renal  veins 
are  obstructed  by  thrombotic  clots.  Tubercular  disease  often  appears, 
probably  from  tubal  disturbance  in  the  neighborhood  of  the  formation, 
to  cause  more  albumin  than  the  pus  can  account  for,  and  it  has  even 
been  stated  that  at  the  outset  of  the  disease  the  urine  may  contain  albu- 
min and  rarely  epithelial  cells.  Cancers  and  other  growths  do  not  neces- 
sarily make  the  urine  albuminous ;  it  may  hapjoen,  indeed,  that  this 
secretion  is  absolutely  natural,  notwithstanding  the  extension  in  the 
kidney  of  large  growths,  so  long  as  these  be  not  exposed  in  the  pelvis ; 
but  traces  of  albumin  are  apt  to  present  themselves  apparently  from 
irritation  of  the  gland  by  pressure  or  contiguity. 

The  urine  may  be  albuminous  from  cystic  disease  as  with  the  granu- 
lar kidney  ;  and  it  commonly  shows  at  least  a  trace  of  albumin,  the 
urine  being  pale  and  of  low  specific  gravity,  if  the  kidneys  have  been 
much  impaired  by  dilatation. 

The  urine,  usually  pale  and  copious,  which  is  passed  after  obstruc- 
tive suppression,  is  sometimes  slightly  albuminous,  whether,  as  has  been 
suggested,  from  compression  of  the  renal  veins,  or,  as  perhaps  is  more 
probable,  from  distention  of  the  tubes,  and  irritation  of  the  gland  by 
its  own  secretion. 

Next  to  structural  disorders  it  is  sufficiently  clear  that  mere  increase  of 
pressure  within  the  renal  vessels,  particularly  when  this  is  connected  with 
venous  obstruction,  may  cause  the  transudation  of  serum.  Dr.  Kobinson 
long  ago  made  the  urine  albuminous  by  compressing  the  renal  vein,  and 
we  see  a  similar  process  in  operation,  as  has  been  enough  dwelt  upon, 
when  the  abdominal  veins  are  compressed  by  the  gravid  uterus  or  the 
whole  venous  system  made  turgid  by  cardiac  obstruction.  Though  struc- 
tural changes  may  be  produced  by  these  causes,  yet  from  the  frequently 
fugitive  nature  of  the  albuminuria  so  engendered,  it  is  certain  that  the 
transudation  may  take  place  quite  independently  of  renal  disease.     Of 


ALBUMINUKIA    IN    KELATION    TO    OTHER    DISORDERS.  307 

the  same  nature  is  albuminuria  of  dyspnoea;  it  is  very  general  to  find  at 
least  a  trace  of  albumin  in  croup,  even  though  this  be  catarrhal,  not 
diphtheritic;  and  the  urine  has  been  found  to  be  temporarily  albuminous 
after  severe  epileptic  convulsion,  no  doubt  from  the  respiratory  embar- 
rassment pertaining  to  it.  To  these  causes  of  increased  blood-pressure 
within  the  kidney  must  be  added  the  influence  of  the  cold  stage  of  ague 
with  the  internal  congestion  which  it  involves,  and  also  the  external 
action  of  cold  in  bathing.  All  these  are  causes  of  albuminuria,  though 
the  kidneys  be  undisturbed,  save  temporarily  in  their  circulation.  We 
may  have  to  add  another.  Increased  arterial  tension  is  a  marked  ac- 
companiment of  certain  diseased  states  with  which  the  kidneys  are  apt 
to  be  granular  and  the  urine  albuminous.  Does  this  increased  arterial 
tension  ever  cause  the  urine  to  be  albuminous  irrespectively  of  renal 
change  ?  This  question  must  wait  for  its  answer  ;  my  own  observation 
so  far  points  to  the  negative. 

Many  of  the  causes  of  albuminuria  her  3  referred  to  have  been  con- 
sidered in  the  preceding  pages  and  need  no  further  notice  ;  with  regard 
to  some  which  relate  less  particularly  to  the  kidneys  a  few  words  are  re- 
quired. 

The  transient  albuminuria  produced  by  the  various  drugs  which  act 
as  renal  irritants  has  been  considered  in  connection  with  tubal  nephritis; 
as  also  has  the  sometimes  more  lasting  condition  which  results  from  the 
renal  exit  of  bile  and  sugar,  and  from  the  influence  of  several  exanthem- 
ata which  presumably  act  similarly  by  discharging  through  the  kidneys 
a  special  morbid  irritant. 

Eeference  Avill  also  be  found  in  connection  with  nephritis  to  the  form 
of  albuminuria  which  has  been  known  to  ensue  upon  extensive  injury  to 
the  skin  by  disease,  or  in  animals  by  the  experimental  arrest  of  its  func- 
tion by  impervious  coverings.  There  is,  however,  another  mode  in 
which  cutaneous  disease  may  render  the  urine  albuminous  ;  I  have  re- 
cently seen  a  case  of  extensive  and  fatal  eczema  in  which  the  kidneys 
had  become  lardaceous,  possibly  in  consequence  of  the  protracted  and 
exhausting  discharge. 

Pneumonia  as  a  cause  of  albuminuria  requires  mention  which  has 
not  yet  been  accorded  to  it. 

This  disease,  though  not  to  be  recognized  as  a  cause  of  enduring 
renal  disease,  is  perhaps  as  frequent  a  cause  of  albuminuria  as  diphtheria 
or  scarlatina.  This  complication  of  pneumonia  has  been  much  studied, 
and  its  phenomena  fairly  exposed  to  view.  The  frequency  of  albumin- 
uria in  this  relation  has  been  variously  estimated.  Parkes  found  it  in 
6  of  13  cases,  and  quotes  Finger,  who  found  it  in  15  of  33  cases,  and 
Becquerel,  who  found  it  in  9  of  21,  giving  a  total  of  30  instances  of  al- 
buminuria among  67  of  pneumonia,  or  a  proportion  of  nearly  4:5  per 
cent.  Dr.  Wilson  Fox  found  the  urine  to  be  albuminous  10  times  in  32 
cases,  and  Griesinger  03  times  in  121  cases.  On  the  other  hand,  Metz- 
gar  failed  to  find  albumin  once  in  48  cases  ;  while  Martin  Solon  and 
Ziemssen  each  found  albumin  only  twice  in  24  cases.  My  own  experi- 
ence, so  far  as  it  relates  to  true  lobar  pneumonia,  more  clearly  corre- 
sponds with  the  figures  of  greater  frequency;  though  with  pleurisy  and 
bronchitis  the  urinary  complication  is  comparatively  rare.  Dr.  Isam- 
bard  Owen,  when  Medical  Kegistrar  at  St.  George's  Hospital,  kindly 
drew  up  for  me  the  following  table,  the  accuracy  of  which  may  be  re- 
lied upon.  From  this  statement  it  appears  that  of  26  cases  of  pneu- 
monia treated  in  St.  George's,  the  urine  presented  more  or  less  albumin 


308 


ALBUMINURIA    IN    RELATION    TO    OTHER    DISORDERS. 


in  all  but  four;  and  of  those  four  the  opportunities  for  observation  were 
not  always  so  frequent  as  to  allow  of  the  inferences  that  the  urine  was 
free  from  albumin  throughout  the  whole  course  of  the  disease.  It 
will  be  observed  that  the  albumin  appeared  at  all  times  between  the 
second  day  and  the  tenth,  and  that  no  fixed  relation  held  between  its 
date  of  appearance  and  that  of  resolution. 


Table  showing   the   Period  of  Alhuminnria   in    Twenty-six   Cases  of 

Pneumonia. 

The  following  table  includes  all  the  cases  of  acute  pneumonia  admitted 
into  St.  George's  Hospital,  from  January  to  August,  1877,  with  nine 
exceptions.  Of  these,  one  was  complicated  with  acute  rheumatism, 
four  were  rapidly  fatal,  and  in  the  remaining  four  other  causes  prevented 
the  collection  of  the  urine. 

The  morning  secretion  was,  as  a  rule,  examined  whenever  obtainable 
until  convalescence  was  approached.  The  fourth  column  of  the  table 
contains  the  result  of  each  examination  made,  whether  positive  or  nega- 
tive. 


<6 

■a 
s 

03 
M 

3)  . 
Q  o 

M. 

,  40. 

6th. 

M. 

,  44. 

7th. 

M. 

,  23. 

1st. 

M. 

,  26. 

3d. 

M. 

,  40. 

8th. 

M. 

,  26. 

1st. 

M. 

,  56. 

14th. 

M. 

,  29. 

5th. 

M. 

,  20. 

8th. 

M. 

,  27. 

8th. 

F. 

26. 

3d. 

Period  of  Resolution. 


Albuminuria. 


Temperature  declined  from  ad- 
mission; normal  by  11th  day, 
on  which  resolution  com- 
menced. 

Crisis  on  night  of  8th. 


Resolution  from  3d  day. 

Resolution  commenced  on  5th 
day. 

Crisis  on  night  of  10th, 


Resolution  commenced  on  4th 

day. 
In  full  resolution  on  admission. 
Temperature  declined  from  Gth 

morning ;    normal     by    9th. 

Resolution    commenced    on 

7th  day, 
In  full  resolution  on  admission. 
In  full  resolution  on  admission. 


Resolution  commenced  on  6th 
day 


Urine  albuminous  on  7th  and  8th 
days;  a  trace  of  albumin  present 
on  10th  ;  a  faint  trace  on  11th ; 
none  on  12th. 

Urine  albuminous  on  10th;  no  albu- 
min present  on  8th.  11th,  12th,  or 
various  subsequent  occasions. 

No  albumin  on  any  day  from  1st  to 
.  5th. 

A  trace  of  albumin  on  4th  and  5th 
days;  none  on  6th,  7th,  9th,  10th, 
or  11th. 

Urine  slightly  albuminous  on  9th 
day;  albuminous  on  10th;  a  trace 
of  albumin  present  on  11th;  none 
on  13th. 

Urine  albuminous  on  2d  day  ;  a 
trace  present  on  4th. 

No  albumin  on  admission. 

Urine  slightly  albuminous  on  5th, 
6th,  and  7th  days;  suppressed  on 
8th ;  free  from  albumin  on  10th, 
11th,  and  12th. 

No  albumin  on  admission. 

Urine  albuminous  on  9th  day;  free 
fromallnunin  on  18th;  collection 
irregular  owing  to  delirium  tre- 
mens. 

A  trace  of  albumin  present  on  5th, 
6th,  7th,  8th,  and  11th  days,  and 
on  discharge;  none  on  9th. 


ALBUMINURIA    IN    RELATION    TO   OTHEB  DISORDERS. 


309 


be 

d  o 

5'fl 

Period  of  Resolution. 

Albuminuria. 

F.,    18. 

5tn, 

Resolution  commenced  on  12th 

Urine  slightly  albuminous  on  9th 

day- 

day;  a  trace  of  albumin  present 
on  11th,  15th,  and  19th :  none  on 
13th  or  16th. 

F.,    32. 

5th. 

Crisis  on  night  of  5th. 

Urine  slightly  albuminous  on  6th 
day;  a  faint  trace  of  albumin 
present  on  10th. 

M.,  17. 

2d. 

Crisis  on  night  of  6th. 

Urine  albuminous  on  3d,  6th,  and 
7th  days  ;  less  so  on  Btli ;  free 
from  albumin  on  9tli  and  11th 
(sodic  salicylate  was  given  from 
the  3d  to  the  6th). 

M.,  80. 

13th. 

Crisis  on  night  of  15th;  resolu- 

Urine slightly  albuminous  on  14th 

tion  commencing  during  the 

and  15th  da,ys;  a  trace  of  albumin 

day. 

prest^nt  on  16tii;  none  on  17th 
and  18th. 

F.,    70. 

nth. 

Resolution  commenced    about 

Urine  slightly  albuminous  on  11th, 

12th  day. 

13th,  and  14th  days. 

F.,    26. 

4th. 

In  resolution  on  admission. 

A  trace  of  albumin  on  7th. 

M.,  13. 

5th. 

Resolution  commenced  on  7th 

Urine   highly  albuminous   on  5th, 

day. 

6th,  and  7th  days;  slightly  so  on 
8th;  free  from  albumin  on  9th 
and  10th. 

F.,  5. 

nth. 

Resolution  commenced  on  12th 
day. 

No  albumin  on  12th  or  17th. 

M.,  24. 

2d. 

Resolution  commenced  on  5th 

A  trace  of  albumin  present  on  4th; 

day. 

none  on  5tli  or  12th. 

M.,  27. 

5th. 

No  resolution  ;  death  on   10th 

day. 
Crisis  on  night  of  7th. 

Urine  loaded  with  albumin  on  8th 

day. 
Urine  slightly  albuminons  on  6th 

M.,  39. 

5th. 

day;  a  trace  of  albumin  pi-esent 

on  7th;  a  very  faint  trace  on  8th; 

none  on  10th. 

M.,  4. 

5th. 

Resolution  commenced  on  8th 

Urine   highly  albuminous  on  5th 

day. 

and  6th  days;  slightly  so  on  9th, 
and  on  discharge  (the  face  was 
puffy,  and  was  said  to  have  been 
so  for  three  weeks  before  the  on- 
set of  the  pneumonia). 

M.,  35. 

2d. 

Resolution  corDmenced  on  7th 

Much  liEematuria  on  2d,  3d,  and  4th 

day. 

days;  lesson  5th;  little  on  6th;  a 
trace  of  albumin  present  on  9th; 
a  faint  trace  on  11th;  none  on 
discharge. 

M.,  54. 

4th. 

Resolution  commenced  on  5th 

A  trace  of  albumin  present  on  4th 

day. 

day;  none  on  7th  or  9th. 

F.,    22. 

5th. 

Resolution  commenced  on  8th 

Urine  albuminous  on  6th  day;  free 

day. 

from  albumin  on  11th  and  12th. 

The  albumin  is  often  enough  to  form  a  bulky  coagulum,  and  it  is 
not  uncommon  for  the  urine  to  contain  blood,  though  not  enough 
to  account  for  the  albumin.  Epithelial  casts  are  generally  to  be  found. 
The  characters  of  the  urine  are  such  as  belong  to  tubal  nephritis,  save 
that,  contrary  to  what  occurs  in  nephritis  as  an  independent  disease, 
the  urinary  solids,  with  the  exception  of  the  chlorides,  appear  to  be  in- 


310  ALBUMINURIA    IN    RELATION    TO    OTHER    DISORDERS. 

creased.  (Edema  is  practically  unknown  as  a  result  of  pneumonic  albu- 
minuria, tliough  Professor  Bartels  mentions,  in  Ziemssen's  Dictionary, 
an  exceptional  instance,  in  which  general  dropsy  with  the  ordinary  symp- 
toms of  acute  nephritis  arose  in  the  course  of  a  genuine  pneumonia. 
This  patient  recovered,  and  I  am  not  aware  that  persistent  renal  disease 
h;i3  ever  been  traced  to  tliis  beginning.  The  albumin  either  disappears 
witii  the  acute  symptoms,  or  withdraws  more  slowly  during  convales- 
cence. There  is  some  variation  in  the  time  at  which  this  urinary  change 
presents  itself,  but  it  does  so  in  most  cases  at,  or  rather  before  the  height 
of  the  disease,  while  tlie  hepatization  is  on  the  increase,  and  the  febrile 
disturbance  great.  The  advent  of  the  albumin  appears  usually  to  an- 
ticipate the  process  of  resolution,  so  that,  with  our  present  knowledge, 
we  can  hardly  adopt  the  theory  which  has  been  advanced  that  tiie  renal 
disturbance  is  due  to  the  irritating  effect  of  the  pneumonic  products  es- 
caping by  the  kidneys.  Nor  can  we  with  more  probability  refer  to  the 
dyspnoea  as  connected  with  the  change  of  secretion;  difficulty  of  breath- 
ing when  extreme,  as  from  laryngeal  disease,  may  cause  the  urine  to  be- 
come slightly  albuminous,  but  with  pneumonia  the  dyspnoea  is  compar- 
atively slight,  and  the  albuminous  addition  considerable. 

The  hypothesis  which  of  late  has  gained-  most  acceptance  is  that  the 
kidneys  are  primarily  implicated  in  a  general  congestion  and  exudation,  of 
which  the  lungs  afford  but  the  most  marked  localization;  it  would  seem, 
however,  that  the  kidneys  are  usually  affected  after  the  lung,  and  less 
severely,  while  the  manner  of  their  disturbance  is  much  that  which  suc- 
ceeds, obviously  as  a  consequent  affection  upon  many  other  febrile  states. 
If  on  such  grounds  we  discard  the  view  that  the  renal  affection  is,  so  to 
speak,  pneumonia  of  the  kidney,  we  may  take  refuge  in  a  supposition 
which  seems  indeed  to  spring  naturally  from  the  facts  of  the  case.  The 
urine  becomes  albuminous,  and  the  evidences  of  tubal  nephritis  arise  at  the 
period  in  the  disease  when  the  essential  urinary  excreta  are  in  extravagant 
excess,  and  the  urinary  water  deficient.  The  increase  relates  to  the 
urea,  the  uric  acid,  and  the  sulphuric  acid;  the  urea  in  particular  may 
be  increased  beyond  the  wont  of  any  other  disease,  excepting,  perhaps, 
diabetes,  where  the  ureal  discharge  occurs  together  with  a  great  flow  of 
urinary  water.  Parkes  found  between  80  and  90  grammes  of  urea  (be- 
tween twice  and  thrice  the  normal  amount)  to  be  secreted  daily  from  the 
sixth  to  the  tenth  days  of  pneumonia;  and  other  observers  bear  similar 
testimony,  both  as  to  the  enormous  amount  of  urea  secreted,  and  as  to 
the  fact  that  the  increase  is  greater  before  than  during  resolution — con- 
nected, tliat  is,  witli  the  febrile  state,  rather  than  with  the  absorption 
and  discliarge  of  inflammatory  })roducts.  It  is  not  improbable  that  the 
kidneys  owe  their  disturbance  to  the  functional  demand  thus  made  upon 
them,  the  attendant  irritation  enhanced  possibly  by  the  want  of  water. 
Observations  are,  however,  wanted  as  to  the  exact  relation  of  the  albu- 
min and  the  other  nitrogenous  components  of  pneumonic  urine.'  Cases 
have  been  reported  in  whicli,  under  this  disorder,  the  urea  has  been  less 
than  in  health;  in  them  albumin  has  been  either  absent  or  in  trifling 
quantity. 

That  cases  of  pneumonia  in  which  albuminuria  occurs  are  more 
fatal  than  others,  does  not  admit  of  doubt.  Probably  this  complication 
is  the  more  apt  to  occur  in  the  more  severe  cases,  while  choking  of  tlie 

'  Observations  upon  the  elimination  of  urea,  by  S,  West,  Med.-Chir.  Trans., 
1874.  ^ 


ALBUMINUKTA    IN    RELATION    TO    OTBER    DISORDERS.  311 

Tiidney  can  but  add  to  the  risk  of  a  disorder  which,  like  pneumonia,  is 
productive  of  refuse  which  belongs  to  this  exit. 

"With  regard  to  cholera  also  a  few  words  have  to  be  added  to  what 
has  found  place  under  the  heading  of  nephritis. 

During  the  cold  stage  of  cholera,  the  urine  becomes  nearly  or  quite 
suppressed,  and  that  which  is  next  secreted  is  albuminous  and  contains 
epithelial  casts.  The  kidney  itself  displays  much  tubal  obstruction  and 
often  early  fatty  change  in  the  epithelium,  while  by  some  observers 
small  vascular  blockings  have  been  described.  Putting  aside  the  latter 
complication,  the  condition,  clinically  and  pathologically,  is  one  of  tubal 
nephritis,  and  has  been  considered  in  its  place  as  such.  But  there  are 
some  further  points  of  interest  with  regard  to  the  way  in  which  this 
condition  is  produced.  It  has  been  repeatedly  asserted  that  the  urine 
becomes  albuminous  only  in  cholera  which  is  truly  Asiatic,  the  presence 
of  albumin  being  regarded  as  a  pathognomonic  symptom  in  this  respect; 
but  albuminuria  with  English  cholera  is  by  no  means  uncommon;  and 
we  have  the  evidence  of  Dr.  G.  Johnson'  that,  in  a  large  proportion  of 
cases  of  ordinary  summer  diarrhoea,  the  urine  first  secreted  after  the  se- 
verity of  the  attack  has  passed  contains  for  a  few  hours  albumin  and  tube 
casts.  Dr.  Johnson  infers  the  existence  in  all  cases  of  a  morbid  poison 
by  which  the  kidneys,  as  well  as  the  bowels  are  irritated;  but  the  experi- 
ments of  Herrmann,^  of  Overbeck,^  and  of  Cohnheim*  enable  us  to  re- 
gard the  matter  in  a  new  light,  by  showing  the  changes  which  the  renal 
function  undergoes  in  consequence  of  the  arrest  and  re-establishment  of 
the  circulation.  By  these  experiments,  it  was  shown  in  the  first  place 
wliat  is  sufficiently  obvious,  that  the  renal  secretion  is  suspended  when 
the  current  in  the  renal  vessels  is  stopped,  whether  by  compressing  the 
renal  artery,  or  the  artery  and  vein  together,  or  the  aorta.  The  removal 
of  the  ligature  and  the  readmission  of  blood  then  causes  in  the  dog  re- 
sults which  are  precisely  analogous  to  those  ensuing  upon  cholera  in  the 
human  subject.  A  condition  of  nephritis  comes  on,  which  lasts  longer 
or  shorter  according  to  the  length  of  time  for  which  the  ligature  has 
been  applied.  The  kidney  becomes  at  once  swollen  and  congested,  and 
the  urine  bloody;  the  renal  vessels  are  found  to  be  dilated  and  liquor 
sanguinis  and  corpuscles  to  have  been  effused.  A  similar  condition  of 
hyperaemia  was  produced  in  other  structures — in  the  ear,  for  example — 
by  a  similar  process,  so  that  it  could  be  demonstrated  as  a  law  which  ap- 
plied to  more  than  one  structure,  that  re-establishment  of  the  circulation 
after  its  arrest  is  attended  with  congestive  or  inflammatory  change.  As 
the  failure  of  circulation  in  the  collapse  of  cholera  is  general,  it  may  be 
asked  why  the  subsequent  inflammation  should  be  most  marked  in  the 
kidney;  possibly  the  arrest  of  circulation  may  be  more  complete  in  this 
organ  than  elsewhere,  in  consequence  of  the  removal  of  water,  which  is 
especially  necessary  to  the  renal  function,  and  presumably  to  its  circula- 
tion. The  double  system  of  renal  capillaries  must  be  little  suited  to 
the  transmission  of  the  viscid  blood  of  cholera. 

Pyrexia  has  often  been  referred  to,  as  if  this  condition,  irrespective 
of  its  origin,  were  a  cause  of  albuminuria.  It  is  undoubted  that  this 
occurs  in  many  pyrexial  states,  but  it  is  open  to  question  whether  the 
complication  is  due  to  the  pyrexia,  or  to  what  has  caused  the  pyrexia. 

'  London  Med.  Record,  vol.  i.  p.  474. 

*  Year  Book  of  Medicine  and  Sargeiry,  1862,  p.  26. 
^  Ibid.  1SG8,  p.  28. 

*  Ziemsseii's  Dictionary,  vol.  xv.  p.  223. 


312 


ALBUMINURIA.    IN   RELATION    TO   OTHER    DISORDERS. 


Dr.  Chaffey,  the  Registrar  at  the  Hospital  for  sick  children,  kindly 
made  at  my  request  at  tliat  institution  some  observations  which  are  con- 
sistent with  the  supposition  that  the  albuminuria  is  not  due  to  the  tem- 
perature per  se.  A  comparison  of  the  cases  of  diphtheria  and  pneumo- 
nia with  those  of  high  temperature  connected  with  tubercle  and  local 
disease  shows  how  much  more  frequent  is  albuminuria  in  the  zymotic 
conditions,  if  we  may  include  pneumonia  under  this  head,  than  where 
no  contamination  of  blood  is  suspected.  It  would  indeed  appear  that 
the  urine  is  albuminous,  not  as  the  result  of  fever,  but  as  the  result  of 
febrile  poison,  or,  in  the  case  of  pneumonia  and  cholera,  of  special  influ- 
ences which  have  been  discussed. 


Initials  of  patient. 


H.  M.,  Feb. 


F. 
K. 
J. 

i 

H. 

J. 

A. 

F. 

E. 

H. 

E. 

E. 

E. 

E. 

B, 

F. 

J. 

J. 

A. 

X. 

E. 
D. 
G. 
L. 
G. 
J. 
E. 
C. 
A. 
A. 
E 
A. 
.\. 
R. 
G. 
F. 
F. 


14,  6  P.M. 

15,  6  A.M. 
18,  6  a.m. 
21,  6  a.m. 
24,  6  a.m. 
29,  6  A.M. 


R 

B 

C,  March  27. 

30. 

F 


C 

J 

B 

D 

Trott. . 
Taylor. 

R 

P 


March  17. 
"       21 


H. 

S.. 


Complaint. 


Diphtheria,  before  tracheotomy. 
"  after  " 


Gungrenous  pharyngitis,  diphtheritic. 

Measles 

Typhoid  


Erysipelas 

Pneumonia,  lobar  or  croupous. 


of  apex. 


Pleuro-pneumonia. . , 
Broncho-pneumonia . 
Bronchitis 


Empyema 

General  tuberculosis. 


Phthisis 

Mesenteric  disease. 


Tubercular  peritonitis. 


Chronic  peritonitis. 

Meningitis 

Psoas  abscess 

Morbus  coxae 


Abscess. 


Acute  periostitis.  . . 
Abdominal  tumors. 


Tempe- 

Albumin in 

rature. 

urme. 

99.8 

none 

101.6 

trace 

99.2 

'< 

99.2 

more 

98.4 

faint  trace 

99.0 

trace 

108.4 

(( 

102.0 

none 

103.8 

<( 

102.8 

" 

102.8 

.-race 

103.8 

a 

104.0 

n 

103.0 

it 

102.8 

faint  trace 

102.6 

bttle 

104.8 

none 

104.6 

te 

104.0 

trace 

101.0 

<< 

102.0 

none 

103.2 

(< 

101.8 

" 

101.0 

" 

104.0 

t( 

103.6 

trace 

103.4 

none 

102.0 

<( 

102.0 

trace 

103.0 

none 

102.0 

<c 

102.8 

" 

102.0 

" 

102.2 

<< 

102.8 

<( 

103.0 

it 

102.0 

ii 

103.0 

(< 

103.0 

" 

103.4 

<( 

101.8 

(< 

101.0 

'< 

103.4 

l( 

101.4 

" 

The  temperatures  were  in  most  cases  taken  in  the  evening.  Tlie  urine  exam- 
ined was  in  each  case  passed  at  the  same  time,  or  as  soon  as  possible  afterwards. 
The  tests  used  were  heat  and  nitric  acid. 


ALBUMINURIA    IN    RELATION    TO    OTHER    DISORDERS.  313 

Claude  Bernard  long  ago  ascertained  that  while  puncture  of  the 
floor  of  the  fourth  ventricle  in  the  centre  of  the  space  between  the 
origins  of  the  auditory  and  pneumogastric  nerves  caused  the  urine  to 
become  saccharine,  a  puncture  '  a  little  higher  up  often  made  it  super- 
abundant and  albuminous.  A  prick '^  just  behind  the  cerebellar  pedun- 
cle in  a  rabbit  caused  the  urine  to  become  both  albuminous  and  sac- 
charine. Further  than  this  the  same  experimenter  found  the  secretion  to 
be  rendered  albuminous  by  injury  to  the  sympathetic  in  the  neck;  and 
to  approach  the  kidney  itself,  he  ascertained  that  when  all  the  nerves 
accompanying  the  renal  blood-vessels  had  been  crushed  by  the  temporary 
pressure  of  a  ligature,  the  kidney  was  subjected  to  a  rapid  process  of 
destructive  inflammation.  Other  observers  have  supplied  further  de- 
tails. Von  Wittick  showed  that  the  urine  became  albuminous  after 
section  of  the  nerves,  vaso-motor  in  function,  which  surround  the  renal 
arter}^  but  not  when  only  those  between  the  artery  and  vein,  secretory 
in  his  view,  were  divided.  The  relation  of  the  nervous  system  to  renal 
secretion  needs  to  be  further  inquired  into,  but  it  is  at  least  evident  that 
arrest  of  the  vaso-motor  influence  causes  albuminuria  probably  by  way  of 
vascular  paralysis  and  organic  congestion.  Whether  the  same  changes 
of  secretion  can  be  produced  by  any  other  form  of  nervous  action  has 
yet  to  be  proved. 

In  the  human  subject  the  influence  of  the  nervous  system  upon  the 
quantity  of  the  urine,  and  upon  the  amount  of  earthy  phosphates  which 
it  contains,  is  indeed  of  daily  experience.  The  watery  urine  of  hysteria 
and  the  characters  of  nervous  urine  in  either  sex  are  well  known.  Sup- 
pression of  urine  has  in  some  instances  ensued  upon  concussion  and  an 
albuminous  condition  of  the  secretion  has  been  known  to  follow  the 
same  accident.  Fischer  describes  transient  albuminuria  as  a  common 
result  of  concussion;  such  cases,  howevei,  come  but  little  under  the 
notice  of  the  physician,  and  have,  in  this  country  at  least,  been  insuffi- 
ciently studied  m  this  respect.  As  a  cause  of  persistent  renal  disease, 
injury  to  the  brain  is  scarcely  recognizable. 

Beyond  such  rare  and  possibly  somewhat  doubtful  instances  of  trau- 
matic albuminuria,  we  have  other  instances  in  which  this  condition  has 
apparently  taken  origin  in  morbid  conditions  of  the  nervous  system.  I 
have  elsewhere  referred  to  mental  disturbance  as  a  cause  of  the  granular 
kidney,  an  association  which  has  been  much  insisted  on  by  Dr.  Clif- 
ford Allbutt.  The  occurrence  of  albuminous  urine  as  a  result  of  mental 
strain  has  been  referred  to  by  Sir  Andrew  Clark,^  who  asserts  as  the  re- 
sult of  personal  observation  that  of  the  young  men  who  compete  for  the 
Indian  Civil  Service  Examinations,  above  a  tenth  become  albuminuric. 
This  statement  may  be  taken  as  illustrating  the  albuminuria  of  adoles- 
cence shortly  to  be  discussed.  Another  nervous  source  for  the  same 
change  of  secretion  has  to  be  referred  to  in  exophthalmic  goitre.  This  was 
carefully  observed  l)y  the  late  Dr.  Warburton  Begbie,  who  showed  that 
in  many  instances  of  this  disease  the  urine  was  markedly  albuminous 
after  food,  though  quite  free  before.*  The  vaso-motor  paralysis  which 
affects  the  thyroid  is  probably  so  far  extended  to  the  kidney  that  the 
blood-vessels  yield  to  the  slight  extra  pressure  which  each  meal  occa- 
sions. 

•  See  Part  I.,  p.  181. 

'  Systeme  Nerveux,  t.  i.,  p.  468. 
"Clinical  Trans.,  vol.  xvi.,  p.  62. 

*  Edin.  Med.  Jouiii.,  April,  1874,  p.  880. 


314-  ALULMINURIA    IN    RELATION    TO    OTHER    DISORDERS. 

Vaso-motor  failure,  whether  as  part  of  a  special  disease  or  of  general 
nervous  depression  or  of  injury  to  the  intra-cranial  part  of  the  system, 
appears  to  be  the  essence  of  nervous  albuminuria;  it  is  easy  to  supply 
the  steps  of  the  process  in  vascular  dilatation  and  congestive  or  inflam- 
matory renal  change. 

Attention  has  been  drawn  recently  to  a  form  of  albuminuria  which 
affects  young  persons,'  mostly  males,  in  their  teens,  or,  to  give  a  wider 
range,  from  about  the  age  of  ten  or  eleven  to  two  or  three-and-twenty, 
which  has  been  called  that  of  adolescents,  and  described  as  intermittent 
or  transitory,  and  as  unconnected  with  organic  disease;  though  there  is 
evidence  that  this  liad  not  entirely  escaped  earlier  recognition.  Sir  W. 
Gull  appears  to  have  been  long  familiar  with  it;  the  leading  features 
Avere  brought  into  prominence  by  Dr.  Moxon  in  the  paper  to  which  I 
have  referred,  and  the  subject  has  now  engaged  attention  long  enough  to 
be  spoken  of  in  the  light  of  experience.  Scarlatina  in  childhood  often 
proceeds  to  the  granular  kidney  in  early  adult  life,  the  event  being  indi- 
cated during  many  years  of  ithe  interval  by  little  else  than  slight  or 
intermitting  albuminuria.  But  apart  from  adolescent  albuminuria  thus 
connected  with  fibrosis,  as  yet  latent  or  nearly  so,  there  are  other  kinds 
in  which  no  persistent  change  can  be  suspected.  The  cases  Dr.  Moxon 
has  especially  called  attention  to — many  of  which  sort  have,  since  his 
paper  has  made  me  watchful  for  them,  come  under  my  own  notice — 
occur  in  this  wise.  A  pallid,  depressed,  and  perhaps  shy  or  sullen  youth 
is  found  to  be  out  of  health;  he  may  have  headache  and  inability  to 
study.  He  has  no  dropsy  or  cardio-vascular  change  or  increased  arterial 
tension.  There  is  sometimes  a  little  pain  in  the  lumbar  region,  more 
often  none,  or  only  some  sensation  along  the  lower  part  of  the  spine. 
The  urine,  which  is  natural  in  appearance,  save  that  it  is  usually  pale, 
has  a  natural  specific  gravity,  and  is  in  normal  quantity,  but  is  found  to 
contain  albumin,  which  varies  much  at  different  times — a  good  deal  after 
breakfast,  little  or  none  before — and  I  may  add  that  in  some  cases  the 
albumin  is  more  than  usually  soluble  in  excess  of  nitric  acid.  It  con- 
tains no  blood,  nor  ever  has  it  done  so.  The  microscope  shows  a  large 
deposit  of  oxalate,  but  usually  no  casts. 

Dr.  Moxon,  who  has  kindly  communicated  to  me  the  results  of  his 
later  experience  (May,  1884),  tells  me  that  in  one  such  case,  where  the 
albumin  was  often  present  at  all  hours,  and  unusually  enduring,  but 
ultimately  entirely  disappeared,  casts  were  found,  but  this  is  certainly 
exceptional.  Dr.  Moxon  has  constantly  convicted  these  patients  of 
masturbation,  and  I  have  been  similarly  successful  in  this  respect,  so 
much  so  that  I  think  there  can  be  no  doubt  that  most  of  the  cases  in 
question  have  this  origin;  but  nevertheless  cases  occur  in  which  this  sus- 
picion does  not  present  itself,  and  in  which  some  other  cause  of  disturbed 
health  is  apparent.  The  albumin,  after  a  longer  or  shorter  time,  ceases 
to  reappear,  its  presence  being  unaccompanied  throughout  by  any  more 
precise  evidence  of  renal  disease  than  the  annemia  which  has  been  ad- 
verted to.  We  have  no  guide  as  to  the  state  of  the  kidney  save  that  its 
condition  is  not  one  of  nephritis.  It  may  be  that  it  becomes  congested 
in  concurrence  with  neighboring  organs,  a  possibility  which  finds  sup- 
port in  the  occasional  though  infrequent  appearance  of  casts. 

'  Dr.  Moxon,  on  Chronic  Intermittent  Albuminuria.  Ouy's  Hospital  Reports 
for  1878.  Dr.  Clement  Dukes,  on  the  Albuminuria  of  Adolescents.  Brit.  Med. 
Jour.,  November,  1878. 


ALBUMINURIA    IN    RELATION   TO   OTHER    DISORDERS.  315 

Albuminuria  from  blood  change,  independently  of  any  structural  or 
dynamic  alteration  in  the  kidney,  sinks  into  the  more  narrow  compass 
the  more  closely  it  is  examined. 

It  has  been  shown  that  all  extraneous  poisons  which  make  the  urine 
albuminous  do  so  by  way  of  renal  irritation;  the  febrile  conditions,  in- 
cluding pneumonia  and  cholera,  frequently  as  they  cause  the  same 
change,  appear  to  do  so  in  association  with  tubal  disturbance.  Putting 
aside  these  causes  of  transient  albuminuria,  and  also  those  in  which,  like 
heart  disease,  dyspnoea  and  ague,  we  recognize  operations  of  venous 
congestion  or  increased  blood  pressure,  there  remain  few  conditions  in 
which  this  state  of  secretion  can  be  unequivocally  traced  to  changes  in 
the  composition  of  the  blood. 

Among  the  most  simple  of  these  is  the  albuminuria  which  some  ob- 
servers have  testified  to  as  the  result  of  the  large  ingestion  of  egg  albu- 
men. Berzelius  found  that,  if  white  of  egg  were  injected  into  the  veins 
or  cellular  tissue  of  animals,  the  urine  became  albuminous;  Claude  Ber- 
nard noticed  the  same  result  in  his  own  person  from  the  eating  a  number 
of  hard  eggs  after  long  fasting;  and  that  raw  eggs  may  produce  the  same 
effect  is  testified  to  by  Brown-Sequard  and  other  observers.  Some  ex- 
perimenters, like  Stokvis,  have  taken  white  of  egg  largely  without  find- 
ing any  albumin  in  the  urine,  but  this  only  proves  that  the  power  of 
assimilation  differs  in  different  persons.  Alimentary  albuminuria  must 
hold  its  place  as  experimentally  possible,  though  not  as  clinically  fre- 
quent. It  has  been  stated  that  the  urine  has  become  temporarily  albu- 
minous as  the  consequence  only  of  dyspepsia;  but,  knowing  as  we  do 
how  often  inconstant  or  periodic  albuminuria  together  with  dyspepsia  is 
the  accompaniment  of  an  early  stage  of  the  granulating  kidney,  particu- 
larly when  this  is  connected  with  gout,  we  can  but  suspect  that  when 
the  urine  has  become  albuminous  with  symptoms  of  indigestion,  the 
kidneys  may  not  have  been  perfectly  sound.  Temporary  albuminuria  has 
further  been  attributed  to  the  rapid  absorption  of  large  serous  effusions, 
but  the  evidence  on  tliis  point  is  by  no  means  conclusive.  In  modern 
experience,  consiiderable  collections  of  this  sort  are  taken  up  without  any 
such  result,  and  we  may  suspect  that  when  the  urine  has  become  albu- 
minous in  such  circumstances,  there  has  been  some  renal  disturbance, 
either  from  blisters,  as  suggested  by  Dr.  Warburton  Begbie,'  which  in 
some  instances  had  been  recently  applied,  or  connected  with  pneumonic 
or  other  change. 

Mere  hydraemia  has  been  thought  capable  of  making  the  urine  albu- 
minous. The  well-known  experiments  of  Mosler''  and  Kierulf  demon- 
strated that  this  result  could  be  produced  l)y  the  injection  of  water  into 
the  veins,  but  the  further  observation  of  Stokvis,  that  the  effusion  of 
albumin  could  be  prevented  by  withdrawing  a  quantity  of  blood  equal 
to  that  of  the  water  introduced,  was  enough  to  show  that  the  result 
was  generally  due,  not  to  the  dilution  of  tlie  blood,  but  to  the  increased 
distention  of  the  vessels.  But  so  much  water  could  be  introduced  as 
to  partially  dissolve  the  crpuscles,  and  give  rise  to  the  escape  of  their 
coloring  matter  together  with  globulin  and  albumin,  as  with  hajmoglo- 
binuria  of  morbid  origin;  but  irrespective  of  such  discharge,  and  with- 
out increasing  intra  vascular  tension,  the  addition  of  water   does  juit 

'.Obsf^rvations  by  Heller,  commented  on  by  Dr.  Warburton  Begbie.  Med.- 
Chir.  Rev.,  1H~)''>.  ]).  57. 

'  Diet,  de  Med.  et  de  Chir.  Pratiques,  p.  335. 


316  ALBUMINURIA    IN    RELATION    TO    OTHER    DISORDERS. 

make  the  urine  albuminous.  The  rapidity,  indeed,  with  which  healthy 
kidneys  will  discharge  any  excess  of  water  which  is  introduced  by  the 
stomach,  without  any  accompaniment  of  albumin,  is  enough  to  show 
that  albuminuria  from  excess  of  water  in  the  blood  has,  at  least  in  the 
human  subject,  no  practical  existence. 

Albuminuria,  as  connected  with  intermittent  haematuria  or  haemo- 
globinuria  needs  no  further  notice  here.  The  urine  in  this  condition 
contains  albumin,  along  with  the  other  matters  of  the  corpuscle,  and  will 
even  remain  albuminous  after  it  has  ceased  to  be  colored;  this,  however, 
is  probably  due  to  the  glandular  irritation  sequent  upon  the  abnormal 
discharge.  Next  come  conditions  of  purpura  and  scurvy.  With  pur- 
pura blood  is  often  largely  discharged  with  the  urine,  and  as  with  inter- 
mittent hematuria,  may  remain  albuminous  after  it  has  ceased  to  be 
bloody.  It  is  possible,  again,  in  this  case,  that  some  degree  of  tubal 
disturbance  has  been  set  up  by  the  passage  of  the  blood.  It  is  said  that 
a  similar  condition  of  urine  sometimes  accompanies  scurvy;  and  in  the 
same  category,  that  of  albuminuria  associated  with,  and  dependent 
upon,  haemorrhage,  may  be  placed  those  instances  in  which  blood, 
whether  in  shape  or  solution,  is  discharged  with  the  urine  in  connection 
with  the  more  malignant  types  of  small-pox,  scarlatina,  and  other  fe- 
brile disorders.  It  is  said  that  in  such  cases  the  blood  is  discharged  in  a 
state  of  solution,  as  with  intermittent  hsematuria;  if  in  such  cases 
albumin  appears  without  the  coloring  matter,  it  must  with  probability 
be  attributed  to  the  occurrence  of  such  transient  nephritis  as  febrile  con- 
ditions are  apt  to  set  up. 

With  regard  to  the  albuminuria  of  pyaemia  and  septicaemia,  the  kid- 
neys are  frequently  the  seat  of  pyaemic  localizations,  and  the  urine  gives 
evidence  accordingly  of  renal  inflammation.  As  to  less  definite  con- 
ditions of  blood-poisoning  to  which  the  term  septicaemia  has  been  ap- 
plied, these  are  sometimes  associated  with  erysipelatous  inflammation 
and  attendant  nephritis,  and  sometimes  have  a  purpuric  character,  to- 
gether with  Avhich  heemorrhagic  transudation  may  take  place  into  the 
urine.  Further  than  this,  Mr.  Henry  Lee'  has  drawn  attention  to  the 
appearance  of  albumin  in  the  urine  often  together  with  the  coloring 
matter  of  the  blood,  but  without  corpuscles,  in  cases  where  clot  or 
effused  blood  has  been  absorbed  after  accidents  or  injuries.  We  know 
that  blood  may  be  taken  up  without  this  result;  probably  the  absorbed 
matter  thus  ejected  has  become,  from  decomposition  or  otherwise,  unfit 
for  the  uses  of  the  system. 

There  are  certain  observations  which  would  seem  to  indicate  that  de- 
rangement of  the  liver  alone  may  cause  the  discharge  of  albumin  by  the 
kidneys.  I  do  not  refer  to  the  common  albuminuria  of  jaundice,  with 
which  the  escape  of  bile  by  the  kidneys  creates  an  oi)vious  condition  of 
tubal  nephritis,  as  evinced  by  the  discharge,  together  with  albumin,  of 
bile-tinted  ej)ithelium  and  tube-casts — this  has  been  considered  else- 
where— but  to  a  possible  albuminous  discharge  l)y  the  kidneys  as  a  con- 
sequence of  hepatic  independently  of  renal  disturbance. 

'  "  On  Albumen  in  the  Urine,  sometimes  in  conjunction  with  the  coloring 
matter  of  the  blood,  as  a  consequence  of  surgical  diseases  and  operations,"  by  H^ 
Lee.     Lancet,  Aug.  21st,  1869,  p.  363. 


CHAPTER  XXIII. 

H^MATUEIA. 

Blood  may  become  admixed  with  the  urine  in  so  large  a  variety  of 
circumstances  that  it  may  be  well  to  classify  them,  to  name  the  more 
important,  and  to  indicate  the  clinical  distinctions  by  which  the  classes 
at  least  are  separated.  It  is  not  needful  to  dwell  upon  the  changes  pro- 
duced in  urine  by  the  presence  of  blood,  further  than  to  indicate  the 
differences  which  attend  differences  of  origin.  It  is  sufficiently  known 
that  the  color  which  blood  imparts  to  urine  is  smoky  or  brown,  if  the 
mixture  be  acid;  pink  or  reddish,  if  it  be  alkaline.  Blood-corpuscles, 
which  readily  fall  to  the  bottom,  and  in  acid  urine  long  retain  an  outline 
which,  though  possibly  not  unaltered,  is  recognizable  with  the  micro- 
scope, furnish  the  best  test  which  exists  for  blood  in  minute  quantity. 
Small  quantities,  even,  can  be  discerned  by  the  unassisted  but  practised 
eye,  as  a  brown  line  which  the  corpuscles  present  at  the  bottom  of  a 
slowly  tilted  vessel.  The  corpuscles  may  be  abundantly  evident,  while 
the  albumin  is  inappreciable.  Similarly,  the  color  of  blood  in  urine  is 
strongly  marked,  and  is  associated  with  an  amount  of  albumin,  suppos- 
ing the  albumin  to  be  only  that  belonging  to  the  blood,  which  often  falls 
short  of  the  expectation  Avhich  the  depth  of  color  has  raised. 

It  is  not  necessary  to  refer  to  the  spectroscope'  as  a  test  for  ordinary 
blood  in  urine,  since  other  means  of  examination  are  more  easy  and 
more  accurate;  it  has  been  used  with  haemoglobinuria  to  declare  its  an- 
alogy with  common  urinary  ha3morrhage  or  indicate  minute  points  of 
difference.     The  results  are  not  very  conclusive. 

The  guaiacum  test  has  its  uses,  the  chief  of  which  is  the  detection, 
not  so  much  of  blood  in  its  entirety,  as  of  the  crystalloids,  the  transuda- 
tion of  which  into  the  urine  may  precede  or  stop  short  of  actual  haemor- 
rhage or  even  of  albuminuria.  Dr.  Mahomed  ^  connects  the  guaiacum 
reaction  with  increased  arterial  tension,  and  relies  upon  this  test  to  de- 
fine a  pre-albuminuric  stage  of  albuminuria.  If  it  should  prove  that 
this  reaction  is  generally  to  be  recognized  before  albumin,  it  would  have 
a  practical  value  which,  perhaps,  we  are  hardly  yet  warranted  in  assign- 
ing to  it.  It  is  at  least  evident  that  the  guaicum  reaction  is  more  often 
afforded  by  albuminous  urine,  in  which  case  it  adds  little  to  our  know- 
ledge, than  by  non-albuminous.  I  examined  12  cases  of  each  sort,  taken 
by  chance  from  among  hospital  patients.  None  of  the  non-albuminuric 
cases  gave  the  reaction  in  question;   it  was  found  in  7  of  the  albuminu- 

'  See  paper  by  Drs.  Forrest  and  Finlayson,  on  "  Spectroscopic  Examination  of 
Urine  in  Hsematinuria."  Glasgow  Med.  Joum.,  1879.  Also  the  Spectroscope  in 
Medicine,  bj'  Dr.  McMunn. 

* "  Tlie  Etiology  of  Bright's  Disease  and  the  Pre-albuminuric  Stage,"  by  F.  A. 
Mahomed.     Med.-Chir.  Trans.,  vol.  Ivii. 


318  H.EMATURIA, 

ric.  The  non-albnminuric  class  comprised  several  varieties  of 
disease  of  the  heart  and  vessels,  pneumonia,  bronchitis,  pleurisy, 
asthma,  and  several  forms  of  paralysis.  The  albuminuric  series  included 
acute  and  chronic  nephritis,  the  granular  and  the  lardaceous  kidney, 
and  albuminuria  from  cardiac  congestion.  The  reaction  was  given  in"o 
cases  of  acute  and  4  of  chronic  disease.  It  was  absent  in  tiie  case  of  car- 
diac congestion,  and  in  that  of  lardaceous  disease.  The  test  can  scarcely 
have  practical  utility  except  when  albumin  is  absent  but  expected. 

The  forms  of  ha^maturia  may  be  first  considered  in  relation  to  the 
source  of  the  blood — whether  from  the  kidney,  the  bladder,  or  the  ure- 
thra— and,  secondly,  if  it  be  derived  from  the  kidney  or  bladder, 
Avhether  it  be  dependent  on  local  or  systemic  disease.  Blood  from  the 
kidney  is,  as  a  rule,  uniformly  mingled  with  the  urine,  which  is  as 
bloody  at  the  beginning  as  at  the  end  of  micturition.  Distinct  or  tangi- 
ble dots  are  exceptional  as  results  of  renal  haemorrhage,  though,  in  jiar- 
ticular  when  the  kidney  has  been  lacerated  by  violence,  the  urine  may 
exhibit  casts  of  the  ureter  in  coagulum  or  small  clots  of  indefinite  shape. 
The  sediment  in  general  is  a  brown  powder,  which  presents  no  shape  ex- 
cept to  the  microscope.  When  separate  clots  are  seen,  the  blood  is  usu- 
ally from  the  bladder,  prostate,  or  outward  passages;  when  they  are  of 
large  size,  it  is  invariably  so.  Thus  the  presence  of  considerable  clots  is 
nearly  conclusive  against  renal  hemorrhage,  though  the  absence  of  clots 
proves  nothing.  Blood  from  the  bladder  is  most  abundantly  passed  at 
the  end  of  micturition;  the  first  urine  may  be  natural  in  appearance, 
the  last  a  mere  collection  of  sanies  and  clot.  Outside  the  body  vesical 
blood  is  less  intimately  mixed  with  the  urine  than  renal,  and  preserves  a 
more  sanguineous  appearance.  Blood  from  the  urethra,  which  has  lit- 
tle importance  medically,  is,  or  at  least  may  be,  discharged  separately 
from  the  urine  and  independently  of  micturition.  These  leading  dis- 
tinctions will  be  assisted  by  such  evidence  of  renal  disease  as  is  afforded 
by  the  existence  of  albumin  disproportionately  to  the  blood,  or  by  the 
presence  of  blood-casts  which  may  possibly  indicate  the  exact  source  of 
the  haemorrhage.  The  vesical  or  prostatic  origin  of  the  blood  may  be 
warranted  by  the  urine  being  ammoniacal,  by  its  depositing  triple  phos- 
phatic  and  tenacious  mucus  along  with  the  blood,  and  not  least  conclu- 
sively by  its  displaying  "  cancer  "  cells,  or  cells  of  the  epithelioid  type  in 
such  abundance  as  to  indicate  a  growth.  "  Cancer  "  cells  often  come 
from  the  bladder,  but  almost  never  from  the  kidney,  the  growths  in 
which  are  commonly  sarcomas,  the  cells  of  which  are  not  shed  whole 
and  abundantly  as  those  of  carcinoma  are  apt  to  be,  but  come  away,  if 
at  all,  impalpably. 

I  have  dwelt  chiefly  upon  the  distinctions  which  may  avail  when  more 
obvious  signs  of  the  nature  of  the  disease  are  wanting.  It  may  be  that 
local  or  constitutional  symptoms  point  so  unequivocally  to  one  organ 
that  there  is  no  room  for  speculation.  The  evidences  of  acute  nephritis, 
of  renal  tumor,  of  stone,  intermittent  haematuria,  purpura,  or  scurvy 
may  be  beyond  doubt.  Dropsy  may  be  equivocal — either  a  result  of 
haemorrhage  or  a  sign  of  renal  disease.  In  a  doubtful  case  it  is  well  to 
look  narrowly  for  *'  bladder  symptoms  " — vesical  tenderness,  pain  in  the 
bladder  or  penis,  frequency  of  micturition,  or  pain  after  it. 

The  chief  varieties  of  hematuria  may  be  stated  in  a  tabular  form, 
with  further  reference  only  to  those  points  of  difference  and  to  such  cir- 
cumstances as  call  for  separate  mention. 


im 


HEMATURIA. 


31» 


From  conditions  of 
the  kidneys. 


From  conditions  of 
tlie  bladder,  pro- 
state, and  uri- 
nary passages. 


Of  uncertain  or  va- 
rious seat,  or 
common  to  sev- 
eral positions. 


Dependent  on  Conditions  of  the   Urinary  Organs. 

{ Injuries — bruises  and  lacerations. 

Albuminuric  changes  of  any  kind,  especially  nephritis. 
I  Associated  with  the  albuminuria  of  pneumonia,  cholera,  and 

the  specific  fevers. 
I  Congestion  from  heart-disease  or  other  mechanical  causes. 

Embolism. 

Renal  pya?mia. 

Renal  disseminated  suppuration  (surgical  kidney), 
j  Tubercle. 
I  Villus. 

Malignant  growths — sarcoma,  carcinoma. 
I  Stone. 
[Strongylus. 

f  Injuries,  surgical  or  accidental,  of  bladder. 

Stone. 

Tubercle. 

Growths,  chiefly  carcinoma,  papilloma,  or  villus. 

V^aricosity  or  local  change  in  mucous  membrane,  naeviis. 

Simple  congestion. 

Cystitis  from  any  cause — gout,  paralysis,  febrile  prostration,, 
etc. 

Enlargement  or  disease  of  the  prostate. 
[Stricture  or  inflammation  of  urethra  or  use  of  instruments. 

'  Simple  hsematuria  (?). 
Hagmaturia  caused  by  mental  emotion  (?). 
"  "         "    bodily  exertion. 

"  "         "    sexual  excess. 

"  vicarious  of  menstruation  (?). 

"  "  of  haemorrhoidal  flux  (?). 

•'  due  to  action  of  irritant  poisons,  cantharides, 

etc. 
"      hydatids. 
"  "      bilharzia. 

"  "      chyluria  (blood  in  this  case  probably  de- 

rived from  bladder). 


Dependent  on  General  Cdnditions. 

f  Haemophilia . 

Scurvy. 

Purpura. 

Haamorrhagic  condition,  sometimes  associated  with  fevers- 
Associated  with      -j      small-pox,  typhus,  etc' 

Relapsing  fever. 

Remittent  fever. 

Ague. 
[  Intermittent  haematuria  or  haemoglobinuria. 


Bleeding  from  the  kidney  tubes  ina}^  occur  in  connection  with  any 
disease  of  the  secreting  tissue  which  gives  rise  to  albuminuria.  It  is 
most  severe  and  continued  with  nephritis,  especially  from  cold.  This 
bleeding,  though  not  of  bad  omen  as  regards  the  result,  is  often  profuse 
and  obstinate;  the  urine  may  be  nearly  black  with  blood  for  weeks,  and 
the  loss  such  as  much  to  aggravate  the  anaemia  proper  to  the  disease. 
But  the  symptom  need  not  greatly  modify  the  treatment  otherwise 
called  for,  or  give  rise  to  much  anxiety.     I  think,  indeed,  that  with  free 

'  These  conditions  are  commonly  associated  with  nephritis,  and  appear  also  in 
another  part  of  the  table. 


320  HEMATURIA. 

bleeding  lasting  disease  is  less  apt  to  ensue  than  "when  there  is  none.  The 
astringent  salts  of  iron  are  of  use,  and  may  be  associated  with  sulphate 
of  magnesia  or  sulphate  of  potash,  so  as  to  relieve  local  congestion,  and 
insure  free  action  of  the  bowels.  Haemorrhage  sometimes  occurs,  occa- 
sionally rather  than  continuously,  with  the  granular  kidney,  and  is 
probably  a  result  of  intercurrent  attacks  of  nephritis.  With  lardaceous 
disease  bleeding  is  less  frequent  and  less  profuse.  Albuminuric  hsemor- 
rhage  is  generally  easily  recognized  by  the  casts  which  accompany  the 
blood;  these  will  probably  contain  blood-corpuscles,  or  will  at  least  dis- 
play the  brown  color  of  blood  if  not  its  distinguishing  forms.  Haemor- 
rhage of  similar  origin  is  sometimes  a  result  of  the  congestion  of  heart 
disease,  though  in  this  case  it  is  less  persistent.  Blood  is  sometimes 
found  in  the  urine  with  all  the  specific  fevers,  the  more  often  with  the 
more  severe.  The  hemorrhage  is  generally  renal  in  origin,  and  due  to 
inflammation  of  the  kidney  or  congestion  akin  to  it;  occasionally  it  de- 
pends on  the  condition  of  Idood  rather  than  of  structures,  and  then  may 
proceed  either  from  the  kidney  or  the  mucous  surfaces.  Enough  has 
been  said  with  regard  to  the  nephritis  of  scarlatina,  measles,  and  erysip- 
elas, and  the  hsematuria  which  so  often  attends  it.  Typhus  may  be 
similarly  accompanied,  the  kidneys  presenting,  after  death,  the  appear- 
ances of  acute  nephritis.  Together  with  albumin  epithelial  and  blood- 
casts  may  have  been  found  in  the  urine,  and  even  blood  in  conspicuous 
amount,  the  latter  addition  being,  according  to  Dr.  Murchison,'  a  dan- 
gerous sign,  connected  possibly  with  a  state  of  blood  as  well  as  of  kidney. 
The  same  evidences  of  renal  inflammation  are  associated,  though  less 
frequently,  with  typhoid,  copious  haematuria  having  been  met  with  for 
the  most  part  in  conjunction  with  other  haimorrhages.^  A  similar  asso- 
ciation is  sometimes,  though  fortunately  not  often,  seen  with  small-pox. 
Often  as  the  urine  is  albuminous  Avith  this  disease,  it  is  seldom  bloody, 
though  it  is  apt  to  be  so  in  the  malignant  form,  in  which  haemorrhages 
occur  from  the  mucous  surfaces  and  in  other  situations. 

Another  source  of  haematuria,  as  the  result  of  typhus,  and  possibly 
also  in  connection  with  other  fevers,  is  to  be  found  in  cystitis,  the  result 
of  neglected  retention." 

With  yellow  fever,  as  with  other  specific '  and  contagious  fevers,  al- 
bumin casts  and  blood  have  been  found  in  the  urine,  apparently  in  con- 
nection with  associated  nephritis.  Kelapsing  fever  is  an  occasional  cause 
of  copious  hsematuria.  Dr.  Murchison"  observed  the  urine  to  be  largely 
bloody,  and  to  contain  albumin  and  blood-casts,  in  both  paroxysms  of 
this  disease,  while  during  the  interval  it  was  free  from  even  a  trace  of 
albumin. 

Connected  with  renal  inflammation,  though  often  transient,  some- 
times coincident  with  a  similar  condition  of  the  pelvis  or  some 
other  part  of  the  urinary  mucous  membrane,  is  the  htematuria  of  irri- 
tant poisons,  represented  by  cantharides  and  turpentine.  Bleeding  of 
this  origin  is  apt  to  occur  together  with  much  vesical  irritation.  It  is 
not  necessary  to  add  to  what  has  been  said  in  connection  with  toxic  al- 
buminuria and  abscess  from  cantharides. 

'  Treatise  on  Continued  Fevers,  2d  edit.,  p.  156. 
^  Ibid.,  p.  533. 
^  Ibid.,  p.  212. 

■»  Article  on  "  Yellow  Fever,"  by  J.  D.  Macdonald,  M.D.  Reynolds'  System  of 
Medicine,  ed.  i.,  vol.  i.,  p.  669. 

^Treatise  on  Continued  Fevers,  p.  369. 


HEMATURIA.  321 

Blood  in  the  urine  often  marks  the  impaction  of  an  embolic  block  in 
the  kidney,  but  neither  in  this  case  is  it  of  long  continuance. 

The  renal  haemorrhages  of  the  greatest  practical  importance  (putting 
aside  for  the  present  that  of  intermittent  hematuria  or  hsemoglobinuria, 
which,  though  renal  in  source,  is  not  so  in  cause)  are  those  which  belong 
to  stone  and  tumor.  The  means  of  distinguishing  tiiem  have  been  de- 
tailed under  the  heading  of  stone  (page  1G3).  The  influence  of  rest  in 
stopping  bleeding  from  stone  supplies  the  most  useful  guide.  The 
bleeding  from  stone  is  less  profuse  and  more  transient  than  that  from 
tumor,  though  sometimes,  when  rest  is  not  attainable,  it  is  such  as  to 
cause  pallor  and  call  for  iron.  I  may  here  mention  two  observations 
with  regard  to  the  bleeding  of  stone,  which  have  not  found  place  else- 
where. Though  it  be  brought  on  by  movement,  it  does  not  always  ensue 
immediately,  but  an  interval  of  a  day  or  more  may  possibly  elapse.  It 
will  sometimes  follow  the  free  use  of  alcohol ;  I  have  known  it  to  do  so 
with  such  constancy  that  an  attack  could  be  brought  on  at  option  with 
beer. 

Growths  to  bleed  must  ulcerate  into  the  pelvis.  They  then  cause 
hemorrhage  which  is  more  profuse,  persistent,  and  unmanageable  than 
that  from  any  other  cause  in  which  the  kidney  is  concerned  ;  neverthe- 
less, it  occasionally  happens  that  the  discharge  will  intermit  or  come  to 
an  end  spontaneously,  or  apparently  give  way  to  the  last  remedy.  I 
have  seen  remission  more  often  sequent  upon  iron  alum  or  tannate  of 
iron  than  from  ergot  or  any  other  styptics.  Ergot  is  of  more  use  with 
the  vessels  of  a  normal  structure  than  with  those  of  a  growth.  The 
great  thin  veins  of  such  sarcomata  as  belong  to  the  kidney  probably  have 
little  contractile  power.  No  casts  are  to  be  found  in  blood  of  this  source, 
but  only  blood-corpuscles,  with  perhaps  some  amorphous  powdery  sedi- 
ment. Cancer  cells,  or  morbid  cells  of  any  kind,  are  conspicuously  ab- 
sent ;  unlike  what  occurs  when  the  disease  is  in  the  bladder,  when  they 
are  often  abundantly  present. 

The  ha?maturia  of  haemophilia  appears  to  be  of  renal  origin,  if  pre- 
ceding pain  in  the  back  is  to  be  taken  in  evidence,  and  is  probably  due 
to  some  such  attenuation  of  the  renal  blood-vessels  as  has  been  observed 
in  other  parts.  Whether  casts  appear  in  these  circumstances,  or  in  what 
guise  the  blood  presents  itself,  I  have  never  had  an  opportunity  of  ascer- 
taining. There  is  at  least  one  instance  on  record  in  which  this  mani- 
festation of  the  haimorrhagic  diathesis  has  caused  death.' 

Diseases  of  the  bladder  and  prostate  yield  blood  to  the  urine  perhaps 
less  persistently,  but  on  occasion  more  profusely,  than  to  those  of  the 
kidney. 

I  think  the  largest  amount  of  blood  I  ever  knew  to  be  discharged  with  the 
urine  was  in  the  case  of  a  gentleman  whom  I  saw  at  Manchester  with  Dr.  Lloyd 
Roberts,  whose  bladder,  as  was  ascertained  jifter  death,  was  the  seat  of  a  ragjied 
cancerous  growth  of  little  thickness,  and  about  two  and  a  half  inches  in  diaiiit-- 
ter.  This  gentleman  began  to  pass  blood  with  the  water  in  occasional  small 
quantities,  without  pain,  frequency,  or  discomfort,  rather  more  than  five  years 
before  his  death.  After  two  and  a  half  years  of  this  he  had  a  sudden  profuse 
haemorrhage,  which  was  followed  by  retention  of  urine  and  much  vesical  distress, 
with  pain  in  the  penis  and  perineum.  Dr.  Roberts  passed  a  catheter,  and  broke 
up  and  evacuated  with  immediate  relief  a  quantity  of  coagulum  with  which  the 
bladaer  was  filled.  At  a  later  epoch  a  recurrence  of  similar  symptoms  made  it 
necessary  to  repeat  this  operation.     After  the  first  profuse  hajmorrhage  the  at- 

'  In  the  case  of  a  boy  eight  j-ears  old,  quoted  from  Grandidier  by  Dr.  Wick- 
ham  Legg.     Treatise  on  Htcinopliilia,  p.  5;>. 
21 


322  H^MATUKIA. 

tacks  were  repeated  every  two  or  three  months — being  brought  on  sometimes  by 
an  effort,  such  as  lifting,  coming  on  sometimes  insidiously  in  the  night,  the  pa- 
tient waking  to  relieve  the  bladder,  but  passing  only  blood,  or  what  looked  like 
it.  The  blood  was  often  passed,  apparently  unmixed,  after  the  urine,  which 
itself  had  presented  a  perfectly  natural  appearance.  During  tlie  attacks  there 
was  much  vesical  irritation,  in  the  intervals  none.  For  the  last  year  the  bleeding 
was  nearly  continuous.  When  I  visited  him  two  months  before  his  death  everj'^ 
vessel  in  his  bedroom  was  full  of  blood  or  blood-like  fluid,  with  large  clots  at  the 
bottom  of  each.  The  patient  described  graphically  the  trouble  he  liad  in  expei- 
Ung  these,  which  were  often  six  inches  long,  and  were  shot  out  only  after  much 
straining.  Some  were  so  bulky,  indeed,  that  it  was  difficult  to  believe  that  they 
had  passed  through  the  urethra.  He  was  blanched,  emaciated,  and  prostrate,  as 
after  such  loss  of  blood  he  could  not  fail  to  be.  Under  the  tannates  of  iron  and 
alumina,  gallic  acid  and  pei'chloride  of  iron,  together  with  the  rest  in  bed  which 
was  now  inevitable,  the  bleeding  finally  ceased,  leaving  the  urine  clear,  albumin- 
ous, and  with  a  plentiful  deposit  of  epithelioid  cells,  which  were  presumed  to  have 
come  from  the  bladder,  but  could  scarcely  have  come  from  it  in  such  abundance 
but  as  the  results  of  a  morbid  epithelial  growth.  These  were  of  large  size,  round, 
pear-shaped,  and  irregularly  elongated  and  tailed.  Without  further  bleeding  the 
patient  gradually  sank,  death  being  due  rather  to  the  constitutional  than  to  the 
local  consequences  of  the  disease. 

Such  hsemorrhage  from  any  cause  is  exceptional :  from  cancer  of  the 
bladder  it  is  often  scanty,  and  for  long  periods  absent.  As  a  rule,  the 
bleeding  of  villous  growths  which  may  not  be  malignant  is  more  profuse, 
and  may  be  directly  fatal,  which  that  of  cancer  seldom  is.  Large  quan- 
tities of  blood,  scarcely  changed  by  the  urine,  and  containing  large  clots 
which  have  formed  in  the  bladder,  and  often  been  expelled  tlience  with 
difficulty,  issue  as  the  result  of  this  condition.  Hare  as  villus  is  in  the 
kidney,  it  is  common  in  the  bladder.  It  is  readily  identified  by  the  find- 
ing with  the  microscope  of  loojjs  and  filaments  of  vascular  structure  often 
entangled  in  coagulum.  These  should  be  looked  for,  repeatedly  if  ne- 
cessary, in  a  case  of  profuse  vesical  hemorrhage.  Villus  is  almost  always 
of  the  bladder,  though  this  formation  has  been  known  to  be  associated 
with  solid  malignant  growths  in  this  situation  or  in  the  kidney.  Such 
a  concurrence  is  too  rare  to  form  an  exception  of  any  practical  import- 
ance to  the  rule  that  villus  is  innocent.  And  it  may  be  added  that  it  is 
very  amenable  to  astringents,  especially  if  locally  applied. 

A  fat  man  of  50  was  under  my  care  in  St.  George's  Hospital  in  the  year  1867 
with  profuse  hsematuria,  vesical  in  character;  the  blood  was  accompanied  with 
large  clots,  which  were  expelled,  however,  without  much  diflSculty ;  and  large 
epithelial  cells,  such  as  might  have  come  from  the  bladder,  were  found  with  the 
microscope.  The  haematuria  was  constantly  present  for  rather  more  than  a 
month,  at  the  end  of  which  he  was  anaemic  to  the  last  degree  and  oedematous. 
After  one  injection  of  the  tincture  of  perchloride  of  iron  (two  drachms  to 
eight  ounces  of  water)  the  bleeding  abruptly  stopped,  the  next  urine  being  free 
from  blood.  The  heemorrhage  reappeared  for  one  day  three  weeks  afterwards, 
but  with  this  exception  remained  absent.  The  patient  rapidly  regained  the  ap- 
pearance and  sensation  of  robust  health,  and  then  went  his  way.  Seven  years 
afterwards  he  had  a  recurrence  of  the  same  symptoms,  came  again  into  the  hos- 
pital, was  treated  again  with  the  perchloride  with  the  same  result  as  regarded 
the  haemorrhage,  save  that  one  or  two  small  coagula  could  still  be  seen  in  the 
urine.  But  the  urine  was  now  albuminous  independently  of  blood,  and  he  died  in 
coma,  the  result  of  concurrent  kidney  disease.  A  papillomatous  growth,  which 
might  equally  well  have  been  described  as  villus,  was  found  in  the  bladder. 

The  readiness  of  villous  growths  to  be  detached  gives  capriciousness 
to  their  course,  and  adds  complication  to  their  symptoms.  Portions,  or 
even  the  whole  will  sometimes  break  away,  and  leave  the  patient  thus 
cured,  or  at  least  completely  relieved.     A  gentleman  who  suffered  from. 


lI.EMATURIA.  323 

an  issue  of  blood  of  this  nature,  became  the  subject  of  a  medical  consul- 
tation.'  During  this  he  had  an  urgent  call  to  pass  water,  and  discharged 
in  response  to  it  a  quantity  of  nearly  pure  blood,  and  with  it  the  villous 
growth,  in  regard  to  which  he  had  sought  advice.  The  riddance  seemed 
complete,  and  with  it  the  cure;  but  in  ten  years  the  disease  returned,  aud 
ended  fatally.  A  brother  of  this  gentleman  died  of  the  same  disease.  I 
have  known  a  portion  of  a  villous  growth  to  become  detached,  but  re- 
main in  the  bladder  to  become  incrusted  with  phosphates,  and  set  up  in- 
dependently as  a  stone. 

I  need  not  dwell  upon  the  forms  of  vesical  haemorrhage  which  more 
often  come  under  the  notice  of  the  surgeon:  those  connected  with  stone 
and  with  enlarged  prostate  are  the  most  common.  That  from  stone  is 
small  and  repeated  rather  than  profuse;  it  is  often  only  microscopic  in 
amount.  Its  obvious  dependence  upon  bodily  movement  is  enough  to 
distinguish  the  hiemorrhage  belonging  to  stone  in  the  bladder  from  that 
due  to  any  other  affection  save  stone  in  the  kidney;  and  with  this  it  can 
scarcely  be  confounded.  Enlarged  prostate  gives  rise  to  more  profuse 
bleeding  than  any  other  vesical  affection,  putting  aside  morbid  growths; 
large  quantities  of  dark  blood,  which,  as  far  as  I  have  seen,  has  less 
tendency  to  clot  than  that  derived  from  cancer  or  villus,  are  thrown  out 
from  this  source  in  separate  outbreaks  rather  than  continuously.  The 
bulk  of  the  blood  passes  from  the  bladder  with  the  urine;  a  few  drops 
usually  alone  after  the  bladder  is  empty.  Bleeding  of  this  origin  is 
usually  associated  with  the  other  concomitants  of  prostatic  disease — ad- 
vancing age,  frequency  of  micturition,  pressure  on  the  rectum — which 
will  be  sufficiently  significant  of  its  source.  I  need  not  dwell  upon  the 
treatment  of  this  form  of  hemorrhage:  sulphate  of  magnesia  and  other 
saline  purgatives  will  relieve  the  congestion  on  which  it  depends;  ergot 
may  be  used  with  advantage,  and  ice  introduced  into  the  rectum  should 
other  measures  fail. 

Among  the  rarer  causes  of  hfematuria  may  be  mentioned  vesical 
naevus.  A  child,''  with  a  malformed  bladder  and  a  large  "mother's 
mark  "  on  the  pubes,  passed  blood  in  its  urine.  It  died  eight  days  after 
birth,  and  a  number  of  prominences  of  vascular  tissue  like  that  of  a 
naevus  were  found  upon  the  vesical  mucous  membrane. 

I  have  lately  seen  a  case  presumably  of  this  nature.  A  gentleman  of  the  age 
of  38,  apparently  in  robust  health,  has  had,  since  the  age  of  16,  three  or  four  at- 
tacks of  haematuria  a  year;  the  bleeding  commonly  presented  itself  with  three  or 
four  micturitions,  and  then  completely  ceased  until  next  time,  the  urine  in  the 
intervals  being  perfectly  natural.  The  urine  which  came  under  my  notice,  in  a 
fit  of  unusual  severity,  in  which  large  clots  had  been  expelled,  looked  like  pure 
blood;  numbers  of  large  spheroidal  nucleated  cells  were  seen  with  the  micro- 
scope, such  as  might  have  come  from  the  bladder.  There  was  some  uneasiness 
and  tenderness  in  the  vesical  region,  and  a  small  quantity  of  blood,  unmixed  with 
urine,  had  often  been  noticed  to  leak  from  the  urethra  with  straining  at  stool. 
The  bleeding  was  never  brought  on,  or  increased,  by  even  violent  exercise.  This 
gentleman  has  five  children,  four  of  whom  have  external  naevi,  and  it  is  to  be 
presumed  that  he  has  a  formation  of  the  same  nature  in  connection  with  the  blad- 
der or  prostate.  The  bleeding  has  hitherto  stopped  spontaneously,  or  under  the 
influence  of  styptics,  chiefly  ergot,  by  the  mouth.  The  injection  of  the  perchlor- 
ide  is,  perhaps,  in  the  future. 

'  The  consultants  were  Sir  W.  Gull  and  Sir  Prescott  Hewett;  the  latter  my 
informant. 

^  Reported  by  Mr.  T.  Holmes,  Path.  Trans.,  vol.  xvi.,  St.  George's  Hospital 
Museum,  series  xii.,  prep.  115. 


324  i;.EMATL-KlA. 

Iltematuria,  like  most  otlier  haemorrhages,  has  been  thought  to  be  vi- 
carious of  menstruation,  and  on  doubtful  evidence.  It  has,  at  least, 
never  been  my  fortune  to  trace  the  urinary  flux  to  this  cause.  And 
whether  such  bleeding  is  ever  vicarious  to  that  of  piles  may  be  also 
taken  into  question.  Tlie  bleeding  of  piles  is  related  to  that  from  the 
stomach  and  bowels  by  a  common  origin  in  cirrhosis,  and  a  common 
source  in  the  portal  vein;  but  the  vascular  circumstances  of  the  kidney 
are  different,  and  the  connection  of  renal  hemorrhage  with  that  of  2)iles 
at  least  remote. 

A  discharge  of  blood  with  the  urine  has  been  said  to  supersede 
asthma  and  to  be  caused  by  mental  emotion;  of  the  first  I  have  no  ex- 
perience; with  regard  to  the  second,  I  may  mention  the  case  of  a  skilled 
medical  observer,  now  in  his  fifth  decade,  who  attributes  the  recurrence 
of  small  urinary  hemorrhage  in  his  own  person  to  excitement  or  men- 
tal tension.  For  twenty-three  years  he  has  been  liable  to  occasional 
bleedings  of  this  sort,  about  eight  attacks  in  a  year  at  most.  These 
were  noticed  as  occurring  with  especial  frequency  after  lecturing;  in  the 
year  of  their  greatest  frequency  five  of  the  eight  took  place  immediately 
upon  the  conclusion  of  this  effort.  It  seemed  probable,  from  the  char- 
acter of  the  hemorrhage,  that  it  was  prostatic  or  vesical. 

Purpura  and  scurvy  are  causes  of  hematuria,  which  are  generally 
made  clear  by  the  concomitant  symptoms.  With  purpura,  blood  is  often 
liberally  extravasated  into  tlie  renal  tissues.  I  have  traced  it  in  cylin- 
ders, and  otherwise  between  the  convoluted  tubes,  and  in  the  areolar  tis- 
sue, especially  that  part  of  it  wliich  surrounds  the  pelvis.  Blood  is 
sometimes  to  be  traced  in  such  close  connection  with  the  pelvic  mucous 
membrane  as  to  suggest  that  this  must  have  given  issue  to  the  discharge, 
and  probably  the  vesical  membrane  also  may  sometimes  give  exit  to  it. 
I  have  found  blood  also  in  the  renal  tubes  and  blood-casts  in  the  urine, 
so  that  the  hemorrhage  may  present  all  the  characters  indicative  of  its 
renal  origin.  The  extravasated  blood  is  corpuscular,  as  a  rule,  though  it 
is  said  that,  in  cases  of  exceptional  severity,  both  of  purjnira  and  scurvy, 
it  has  appeared  in  the  dissolved  state  to  Avhich  the  term  hemoglobinuria 
has  been  given.  Of  this  I  have  had  no  experience.  It  may  be  added, 
to  complete  in  this  place  as  miich  as  need  be  said  of  renal  purpura,  that 
beyond  the  appearance  of  blood  in  the  urine,  there  are  usually  no  symp- 
toms to  point  to  the  local  change.  A  marked  example  under  my  ob- 
servation was  in  a  case  of  general  purpuric  extravasation  connected  with 
jaundice  and  obstruction  of  the  common  hepatic  duct  by  hydatids. 
The  kidney  was  deeply  yellow  and  liberally  dotted  with  interstitial  ecchy- 
moses.  It  is  not  necessary  to  particularize  the  treatment  needful  for 
purpuric  hematuria,  which  is  that  of  the  primary  disorder. 

Infants  who  are  brought  up  by  hand,  especially  when  milk  has  been 
withheld  or  insufficiently  given,  are  liable,  at  about  the  time  of  teething, 
to  a  form  of  hematuria  which  cannot  be  described  as  otherwise  than 
scorbutic,  though  the  superficial  ecchymoses  may  be  slight  or  even 
absent,  and  there  be  no  discharge  of  blood  save  with  the  urine.  I  have 
lately  been  consulted  in  five  such  cases,  and  made  aware  of  a  sixth.  The 
children  varied  in  age  when  attacked  from  4i-  to  11  months.  In  all  the 
diet  had  been  conspicuously  wanting  in  fresh  milk;  the  substitutes  whicii 
were  employed  will  be  presently  indicated.  The  urine  in  every  case  had 
a  full  sanguineous  color,  remained  so  for  many  weeks,  and  ceased  to  be 
so  under  the  influence  chiefly  of  milk.  The  blood  in  each  case  was  cor- 
puscular; the  urine  not  albuminoiis,  save  in  one  instance,  beyond  what 


H^MATUKIA.  o'JO 

was  apparently  due  to  the  Wood;  casts  were  found  in  three  cases,  while 
in  the  otliers  hirge  epithelial  cells,  with  more  or  less  mucus  or  pus,  sug- 
gested that  the  blood  proceeded  from  the  urinary  surface  rather  than 
from  the  kidney  substance. 

The  circumstances  of  these  cases,  the  presence  or  absence  of  super- 
ficial haemorrhages  and  of  changes  in  the  gums,  would  permit  some  to 
be  described  as  simple  hannaturia,  others  as  purpura,  others  as  scurvy. 
It  is  clear  that  all  were  of  the  same  nature,  however  restricted  the  symp- 
toms, and  akin  rather  to  scurvy  than  any  other  condition.  Tiiey  suffi- 
ciently show  that  Nestle's  food  and  Swiss  milk  are  not  to  be  regarded  as 
substitutes  for  fresh  milk  in  the  process  of  bringing  up  by  lumd,  though 
as  an  addition  to  fresh  milk  and  water  Swiss  milk  can  often  be  advan- 
tageously used. 

To  allege  the  occurrence  of  simple  hoematuria,  of  hematuria  unac- 
companied by  any  alteration  in  blood  or  tissue,  is  almost  to  assert  the 
existence  of  an  elfect  without  a  cause.  But,  nevertlieless,  it  is  matter  of 
experience  that  the  urine  will  sometimes  become  bloody,  slightly  or  pro- 
fusely, and  will  so  remain  for  a  longer  or  shorter  time,  and  then  will 
cease  to  be  so  without  our  being  able  to  obtain  any  clue  as  to  the  cause, 
either  of  the  disorder  or  its  cessation.  Sometimes  such  Inemorrhage  may 
be  small  and  transient  and  apparently  connected  with  some  general 
liability  to  hemorrhage,  as  shown  by  the  frequency  of  slight  nose-bleed- 
ings. In  other  instances  profuse  and  even  dangerous  hgematuria  has 
come  and  gone  thus  inexplicably. 

I  could  mention  cases  in  which  free  and  protracted  haemorrhage  with 
the  urine  has  thus  come  and  gone  without  declaring  its  nature,  either  by 
its  characters  or  its  sequelae.  Such  haematuria,  however,  is  not  to  be 
called  simple  but  obscure.  A  non-malignant  bleeding  growth  is  the  ex- 
planation which  usually  commends  itself. 

Malaria  is  a  fruitful  source  of  hajmorrhage.  Whatever  processes  con- 
tribute to  the  extravasation,  there  is  at  least  one  agency,  the  results  of 
which  are  simple  and  obvious,  the  driving  of  the  blood  out  of  vessels 
temporarily  constricted  into  others  that  are  not  so.  If  it  be  that  some 
burst  or  leak,  it  is  only  what  is  to  be  expected.'  The  liver  has  been 
found  studded  with  clots  of  extravasation,  the  stomacii  and  bov/els  with 
ecchymoses;  extravasations  have  been  found  within  and  upon  the 
walls  of  the  heart,  and  in  connection  with  the  brain  and  the  retina. 

An  amputated  stump  has  been  known  to  bleed  periodically  under  the 
influence,  as  was  thought,  of  a  previously  contracted  ague,  and  to  cease 
to  do  so  under  that  of  quinine.' 

The  association  of  bloody  urine  with  malaria  has  long  excited  notice. 
Prout  regarded  this  influence  as  predisposing  to  urinary  hajmorrhage 
rather  than  directly  inducing  it,  enhancing  the  effect  of  stones  and  bleed- 
ing structures,  and  making  profuse  what  might  otherwise  be  a  slight  dis- 
charge. The  occurrence  of  haemorrhage  from  the  kidney  during  an 
ague  fit  is  a  matter  of  old,  though  not  frequent,  experience.  The  void- 
ing of  bloody  urine,  after  pain  in  the  loins,  at  the  neck  of  the  bladder, 
and  in  the  gians,  was  common  with  the  severe  intermittents  which  gave 
so  large  a  mortality  to  the  Walcheren^  expedition.     I  have  elsewhere  re- 

'  Retinal  Hcemorrhages  and  Melancemia  as  symptoms  of  Ague,  by  Stephen 
Mackenzie,  M.D. 

'  Intermittent  Hcemorrhage from  Malarial  Influence,  by  Surgeon-Major  Porter. 
Med.-Chir.  Trans.,  vol.  lix. 

^  Dr.  J.  B.  Davis  on  the  Walcheren  Fever,  p.  37. 


326  HEMATURIA. 

ferrod  to  the  experience  of  Dr.  Elliotsoii  upon  this  point,  and  tliere 
Avould  be  no  difficulty  in  adducing  tliat  of  other  observers  to  the  effect 
that  mahirial  fevers,  whetlier  of  the  intermittent  or  remittent  type,  are 
occasionally  productive  of  this  haemorrhage.'  A  form  of  malarial  hema- 
turia, after  death  from  which  blood  is  found  in  the  kidney  tubes,  has 
been  described  by  Dr.  Joseph  Jones,  of  New  Orleans,  as  resembling 
yellow  fever,  but  distinct  from  it;^  and  we  have  testimony  from  Mauri- 
tius of  a  "paludal  fever "^  which  appears  to  be  irregularly  periodic,  in 
which  the  stage  of  rigor  is  regularly  followed  by  renal  haemorrhage.  The 
attack  is  accompanied  by  either  a  general  condition  of  jaundice,  involving 
the  eyes  and  skin,  or  else  extensive  subcutaneous  and  submucous  haemor- 
rhages of  a  purpuric  character.  We  are  not  told  whether  the  blood  in 
the  urine  in  these  cases  is  corj^uscular  or  disintegrated;  but  the  deficiency 
is  supplied  by  a  case  of  fatal  malarial  fever  contracted  in  Minorca,  in 
which  the  symptoms,  inclusive  of  the  subcutaneous  haemorrhages  and  the 
yellowness  of  skin,  indicate  a  similar  condition.  In  this  instance  the 
urine  was  loaded  with  blood  which  was  entirely  disintegrated  and  in  all 
respects  characteristic  of  hgemoglobinuria  the  malarial  origin  of  which  is 
in  question. 

Such  cases,  where  definite  malarial  disease  is  accomj^anied  by  the  typ- 
ically disintegrated  urine,  form  an  inseparable  link  between  the  he- 
maturia of  ague  and  the  variously  named  intermittent  hematuria,  the 
recognition  and  the  definition  of  which  depend  on  the  pulverization  of 
the  blood-discs.  The  analogy  between  the  attacks  of  this  affection  and 
of  ordinary  ague  is  sufficiently  obvious.  It  is  beyond  question,  as  has 
been  shown  in  another  part  of  this  volume  (page  276),  that  a  significant 
proportion  of  those  who  suffer  from  this  form  of  hematuria  have  either 
had  ague  or  been  notoriously  exposed  to  the  malarial  influence.  The 
point  of  inseparability  between  the  two  diseases  appears  to  lie  between 
ordinary  ague,  every  recurring  fit  of  which  is  accompanied  by  hematuria, 
and  intermittent  hematuria,  the  fits  of  which  recur  with  regular  periodic- 
it}".  If  it  should  prove,  as  I  suspect  it  will,  that  the  blood  passed  with 
ague  is  generally  disintegrated,  as  in  the  case  which  has  been  cited,  then 
it  must  be  inferred  that  intermittent  hematuria  is  but  a  variety  of 
malarial  fever. 

The  solution  of  blood-corpuscles  in  the  body  and  the  exit  with  the 
urine  of  the  coloring  matter  together  with  albumin  is  not  peculiar  to  in- 
termittent hematuria,  though  charactistic  of  it;  a  lesser  amount  of 
blood-pigment  together  with  albumin  has  been  found  in  the  urine  with 
various  states  of  septicemia  and  blood-poisoning,  which  have  been  suf- 
ficiently referred  to.  It  would  appear  that  any  of  the  numerous  agencies 
which  tend  to  dissoh'e  or  disintegrate  the  blood  Avithin  the  body  may 
give  rise  to  more  or  less  of  this  condition. 

The  treatment  of  hematuria  generally  resolves  itself  into  that  of  the 
diseases  on  which  it  depends.  When  from  stone,  absolute  rest  is  of  the 
first  importance;  when  from  growths,  active  movement  should  be  avoided, 

'  See  p.  1178.  Also  Herz  on  Malarial  Diseases,  Zieinsseii's  Cyclopcedia,  vol.  ii. 
p.  641. 

'See  the  New  Orleans  Med.  and  Surg.  Journ.  for  February,  1878.  "Observa- 
tions on  Malarial  Haematuria,"  by  Dr.  Joseph  Jones,  quoted  in  Lancet  for  April 
20th,  1878,  p.  595. 

^  "On  the  treatment  of  a  severe  form  of  Paludal  Fever,  with  Icterus  and 
Renal  Haemorrhage,"  bv  J.  Labonte,  Port  Louis.  Mauritius.  Edin.  Med.  Journ., 
May,  1876,  p.  1006. 


HEMATURIA.  327 

though  rest  in  bed  is  attended  with  little  advantage.  The  kidney  is 
not  to  be  reached  by  cold  superficially  applied,  or  to  be  directly  depleted 
from  the  loins;  it  may  be  influenced  by  styptics  taken  by  the  mouth, 
iron  alum,  tannate  of  alumina,  gallic  acid,  acetate  of  lead,  Avitch-hazel, 
and  ergot,  or  by  the  last  of  these  introduced  hypodermically.  Local 
congestion  may  be  lessened  by  saline  purgatives — sulphate  of  magnesia, 
perhaps  the  best  for  the  purpose.  This  may  be  given,  as  a  general 
rule,  when  the  bleeding  depends  either  on  albuminuric  disease  or  renal 
or  prostate  congestion.  Ice,  though  useless  upon  the  loins,  may  be  of 
service  in  the  rectum  when  the  bleeding  is  from  the  prostate  or  bladder. 
For  malarial  and  intermittent  ha?maturia,  quinine  in  large  doses  and 
long  continued  is  the  remedy,  often  usefully  associated  with  the  astrin- 
gent salts  of  iron.  I  need  not  add  to  what  has  been  already  said  as  to 
the  necessity  of  fresh  milk  with  the  scorbutic  ha?maturia  of  infants. 


CHAPTER  XXIV. 
SUPPEESSION   OF   URIXE. 

Though  suppression  of  urine  as  a  symptom  of  renal  disease  has  been 
referred  to  in  various  parts  of  this  work,  it  ma}'  be  convenient  to  phice 
in  juxtaposition  the  several  disorders  upon  which  it  ensues,  and  the 
circumstances  which  attend  the  occurrence. 

Suppression  of  urine  may  be  conveniently  considered  as  of  two  kinds: 
first,  renal  suppression,  depending  on  disease  of  the  kidney  or  of  the 
urinary  or  vascular  channels  in  immediate  connection  Avith  it;  secondly, 
systemic  suppression,  in  which  the  gland,  though  natural  in  structure, 
ceases  to  act  in  consequence  of  an  intiuence  external  to  itself,  which  in- 
volves the  whole  system  in  its  morbid  ojjeration. 

Rexal  Suppression. 

There  are  many  conditions  of  kidney  which  are  attended  with  par- 
tial suppression  of  urine;  others  in  which  the  absence  of  urine  is  com- 
plete. As  a  rule,  partial  suppression  depends  upon  disease  of  the  secret- 
ing structure;  total  suppression  upon  a  mechanical  obstruction  in  the 
renal  outlet. 

Partial  suppression,  or  in  other  words  extreme  scantiness  of  urine, 
sometimes  results,  as  described  elsewhere,  from  disease  of  the  secreting  sub- 
stance of  the  kidney.  With  tubal  nephritis  especially  the  diminution  is 
sometimes  extreme.  There  is  a  rapidly  fatal  form  of  the  disease,  consequent 
upon  scarlatina,  in  which  the  tubes  become  early  and  all  at  once  filled  with 
a  fibrinous  exudation.  The  urine  is  usually  free  from  blood,  of  a  deep 
yellow  color  and  high  specific  gravity;  it  is  generally  loaded  with  albu- 
min, though  cases  have  been  known  in  which  under  these  circumstances 
albumin  has  been  totally  absent;  and  it  abounds  with  strongly-defined 
fibrinous  casts.  This  form  of  scarlatinal  nephritis  is  illustrated  in 
the  case  of  Vallance.  His  minimum  of  urine  in  the  twenty-four 
hours  was  45  centimetres,  or  about  an  ounce  and  a  half.  Sometimes  in 
similar  cases  the  secretion  is  even  more  scanty,  falling  to  a  few  drachms 
in  the  day,  while  less  than  an  ounce  daily  is  passed  for  several  days  to- 
gether. Such  cases  are  usually  fatal  by  way  of  ura^mic  disturbance  of 
the  brain,  though  it  may  happen  that  this  result  is  anticipated  by  one 
of  the  forms  of  acute  inflammation,  to  which  children  with  nephritis 
are  especially  liable. 

The  urine  may  also  be  remarkably  diminished  in  that  highly  con- 
gestive nephritis  Avhicli  cold  sometimes  produces  in  grown  persons. 
Under  this  condition  the  urine  is  always  loaded  with  albumin,  and  of  high 
specific  gravity.  It  is  generally  l»lack  with  blood  and  full  of  thick 
casts.     The  case  of    Benjamin  Patrick,    in  which    on   one    occasion 


SUPPRESSION    OF    UKINE.  329 

only  two  ounces  of  urine  were  voided  in  the  twenty-four  hours,  may 
serve  as  an  example  of  this  affection,  while  a  still  more  striking  in- 
stance is  afforded  in  that  of  Lord  Z 's  groom,  who  passed  during 

the  last  five  days  of  the  disease  only  three  and  a  half  ounces  of  urine, 
the  quantity  for  one  day  and  night  having  fallen  as  low  as  five 
drachms.'  This  affection,  like  the  scarlatinal  form,  is  rapidly  fatal,  and 
as  a  rule  by  cerebral  urajniia.  Such  affections  of  the  kidney,  much  as 
they  may  lessen  the  production  of  urine,  rarely  cause  total  suppression, 
but  it  is  worth  remarking  that  though  the  suppression  is  but  partial, 
death  often  ensues  in  shorter  time  than  where  as  a  consequence  of  me- 
chanical obstruction  the  suppression  is  absolute.  Towards  the  close  of 
granular  degeneration  the  urine  may  fall  considerably  below  the  habitual 
amount,  and  may  even  on  the  approach  of  death  be  absent  for  many 
hours. 

In  an  advanced  stage  of  lardaceous  disease  the  urine,  once  super- 
abundant, may  become  very  scanty;  but  there  is  seldom  such  diminution 
as  has  been  recorded  with  other  forms  of  albuminuria. 

Suppression,  for  the  most  part  partial,  but  occasionally  total  for  a 
short  time,  may  occur  when  the  kidney  is  the  seat  of  suppuration, 
whether  this  be  of  the  limited  sort,  which  is  occasionally  produced  by  an 
extenuil  injury,  or  be  disseminated  as  the  result  of  pyi'emia  or  of  septic 
urinous  absorption.  A  remarkable  instance  of  disseminated  renal  sup- 
puration consequent  on  scarlatina  is  related  by  Dr.  Bates,-  of  New  York, 
in  Avhich  for  the  nine  days  preceding  death  the  total  of  urine  secreted 
did  not  amount  to  half  an  ounce.  An  instance  of  transitory  suppression 
in  connection  with  a  traumatic  abscess  of  tlie  kidney  is  given  from 
Rayer  at  page  2.  The  urine  was  absent  during  one  day,  the  secretion 
reappearing  on  the  following  with  the  admixture  of  pus.  Suppression 
in  connection  with  renal  pytemia  is  exemplified  in  the  case  of  AVil- 
liam  Long,  The  outset  of  the  pyasmic  affection  in  the  kidney  was 
marked  by  a  suspension  of  micturition  for  forty-eight  hours;  at  the  end 
of  this  period  five  ounces  of  urine  were  removed  with  the  catheter,  so 
that  the  suppression  was  then  only  partial.  The  urine  when  obtained, 
and  for  the  rest  of  the  patient's  life,  was  very  deeply  colored  and  albu- 
minous. Blood  and  pus  corpuscles  and  cells  of  renal  epithelium  were 
seen  both  scattered  and  entangled  in  fibrinous  casts. 

Those  cases  of  renal  abscess  in  which  the  suppression,  though  usually 
incomplete,  may  for  a  short  time  be  total,  lead  us  from  partial  suppres- 
sion or  extreme  scantiness  of  urine  to  the  circumstances  in  which  sup- 
pression is  complete  or  the  secretion  totally  absent. 

As  a  corollary  to  the  suppression  of  the  disseminated  suppuration  of 
local  origin  may  be  placed  the  fact  that  occasionally  after  catheteriza- 
tion and  operations  upon  the  urethra,  the  urine  has  become  suppressed 
and  the  kidneys  have  been  found  intensely  congested.  It  is  probable 
that  this  condition  is  but  the  early  stage  of  the  suppurative  process, 
which  has  been  sufficiently  dwelt  upon,  Xephrectomy,  ovariotomy,  and 
other  operations  involving  the  abdominal  and  pelvic  organs,  have  been 
followed  by  suppression  apparently  of  a  different  kind,  Mr.  Godlee  * 
removed  by  abdominal  section  a  kidney  which  was  the  subject  of  calcu- 

See  case  of  scarlatinal  nephritis  reported  by  Dr.  Roberts  in  the  Lancet,  1868» 
p.  655. 

''  Med.  Record,  Oct.  UJtli,  1880,  p.  431. 
^  Clin.  Trans.,  vol.  xv.,  p.  13-1. 


330  8DPPRES8ION    OF    URINE. 

Ions  pyelitis  (p.  189).  The  patient  survived  the  operation  for  twent}-^- 
four  hours,  for  the  hist  twelve  of  which  only  an  ounce  and  a  half  of 
urine  was  secreted.  The  preceding  urine  was  black  with  carbolic  acid 
absorbed  during  the  operation.  The  remaining  kidney  presented  a  nor- 
mal appearance  to  the  naked  eye,  and  practically  so  to  the  microscope. 
Mr.  Howard  Marsh  '  (p.  190)  removed  in  })art,  tlirough  the  loin,  a  sac- 
culated kidney.  Complete  suppression  of  urine  followed  the  operation, 
and  death  at  the  end  of  thirty  hours.  The  remaining  kidney  was  ''fairly 
healthy.'^  The  capsule  Avas  adherent,  and  there  were  two  or  three  small 
cysts  on  the  surface,  but  tliere  was  nothing  to  indicate  advanced  disease. 
Much  temporary  diminution  of  urine  has  been  known  to  follow  ovariot- 
omy, as  in  a  case  recorded  by  Mr.  Thornton.^  How  the  suppression  is 
produced  in  the  circumstances  which  have  been  adverted  to  is  not  very 
clear.  It  is  not  from  any  visible  change  in  the  kidney  itself.  It  must 
be  taken  into  question  whether  it  is  to  be  hypothetically  attributed  to  an 
inhibiting  nervous  influence,  or,  what  is  more  consistent  with  other  ex- 
perience, to  the  collapse  produced  by  the  operation,  or  the  general  fail- 
ure of  function  which  may  precede  death. 

The  most  striking  cases  are  those  which  have  been  described  as  ob- 
structive, the  suppression  being  due  to  a  substantial  barrier  between  the 
mammillary  processes  and  the  bladder. 

Putting  aside  the  rare  occurrence  of  arterial  obstruction,  and  the  ob- 
vious systemic  causes  of  suppression — collapse,  intestinal  stoppage, 
cholera,  and  poison — it  is  at  least  of  exceeding  infrequency  to  find  the 
secretion  of  urine  arrested  for  forty-eight  hours,  and  that  totally,  except 
there  be  a  palpable  obstacle.  And  where  this  exists  it  is  due  in  nine 
cases  out  of  ten  to  stone.  It  is  only  needful  here  to  recapitulate  the 
general  character  of  the  affection  and  to  describe  the  causes,  uncon- 
nected with  stone,  to  Avhich  it  may  be  due.  When  mechanical  ob- 
struction produces  suppression,  either  both  kidneys  are  simultaneously 
obstructed,  or  else,  wliat  more  often  happens,  the  obstructed  kidney  is 
the  only  source  of  urine,  the  other  having  been  incapacitated  by  pre- 
vious disease. 

Calculi,  for  example,  may  be  symmetrically  disposed  in  the  two  kid- 
neys; or,  on  the  other  hand,  one  kidney  having  been  sacculated  or  atro- 
phied by  a  past  fit  of  stone,  the  ureter  belonging  to  the  other  may  be- 
come occluded  by  a  similar  impediment  and  a  total  stoppage  ensue.  Ex- 
amples of  both  these  occurrences  have  been  related. 

Suppression  of  urine  may  be  due  to  simultaneous  sacculation  of  both 
kidneys — double  hydronephrosis,  as  it  is  called — whether  due  to  calculi 
or  to  congenital  or  other  obstruction;  and  it  may  be  produced  by  morbii 
growths,  which  are  so  circumstanced  as  to  press  at  the  same  time  upon 
both  ureters.  A  case  of  double  hydronephrosis  has  been  quoted  in  which 
suppression,  for  the  most  part  incomplete,  was  succeeded  by  copious  dis- 
charges of  urine  and  coincident  diminution  of  an  elastic  lumbar  swell- 
ing. Renal  tumefaction  lessening  suddenly  Avith  increase  of  urine  may 
be  regarded  as  characteristic  of  the  affection.  The  bowels  in  the  same 
case  were  obstinately  confined,  in  consequence,  as  was  found,  of  com- 
pression of  the  descending  colon  by  the  cyst  representing  the  left  kid- 
ney.     From    the  apposition  of   the  colon  and    the    kidney  intestinal 


'i7nvy.,  p.  140. 
'  Ibid.,  p.  144. 


fl 


SUPPRESSION    OF    URINE.  331 

obstruction  may  often  be  suggestive  of  renal  enlargement.  These 
circumstances,  together  with  other  evidences  of  renal  tumor,  will  suffice 
to  distinguish  hydronephrosis  as  a  cause  of  suppression  from  the  other 
conditions  to  which  the  arrest  may  be  due.  A  further  presumption  of 
hydronephrosis  in  a  case  of  suppression  may  be  found  in  the  recurrence 
of  urinous  sweating.  Suppression  of  urine  from  obstruction,  unaccom- 
panied Avith  dilatation  of  the  kidney  or  vesical  retention,  does  not  give 
rise  to  this  symptom,  which,  on  the  contrary,  is  sometimes  strongly 
marked  with  hydronephrosis.  Urinous  exhalations  from  the  skin  are 
generally  associated  with  the  accumulation  and  resorption  of  urine.  It 
is  scai'cely  necessary  to  repeat  that  to  produce  suppression  hydronephro- 
sis must  exist  on  both  sides,  or  if  it  be  confined  to  one,  the  ureter  of  the 
healthy  kidney  must  be  obstructed  by  some  other  means. 

Lastly,  suppression  may  result  from  the  consentaneous  obstruction 
of  both  ureters  by  a  morbid  growth.  Growths  which  produce  this  effect 
are  usually  cancerous,  and  arise  in  connection,  not  with  the  kidney  or 
ureter,  but  with  one  or  other  of  the  pelvic  viscera  which  occupies 
the  median  line.  Tumors  which  originate  in  the  kidney  or  ureter  are 
usually  confined  to  one  side,  leaving  the  gland  on  the  other  free  to  act. 
When  both  ducts  are  occluded  the  disease  has  commonly  arisen  external 
to  and  between  them  in  connection  either  with  the  bladder  or  prostate, 
or  with  the  uterus  or  vagina.  Growths  in  connection  with  these  organs 
are  apt  to  start  nearly  equidistant  from  the  ureter,  and,  spreading  to 
the  right  and  left,  to  involve  both  simultaneously  or  in  succession.  Less 
often  both  ureters  have  been  known  to  have  become  occluded  by  growths 
which  have  begun  in  the  ovary. 

Suppression  of  urine  may  be  produced  by  disease  of  the  bladder  itself. 
A  woman  died  in  the  obstetrical  ward  at  St.  George's  Hospital  after 
suppression  of  urine  which  was  complete,  as  far  as  was  known,  for  ten 
days,  excepting  that  on  the  sixth  day  she  fancied  she  passed  a  little  in  a 
bath.  It  was  found  that  the  bladder  was  the  seat  of  extensive  encepha- 
loid  growth  by  Avhich  the  orifices  of  both  ureters  were  obstructed.  The 
growth  was  primary  to  the  bladder. 

In  cases  of  suppression  from  growths  the  symptoms  of  the  primary 
disease  are  usually  obvious.  Growths  cause  suppression  far  less  often 
than  calculi.  The  symptoms  of  obstructive  suppression,  putting  aside 
those  which  are  due  to  the  special  cause,  are  much  the  same  whatever  be 
the  nature  of  the  obstruction.  They  have  been  described  in  connection 
with  calculi.  The  urine,  if  any  be  passed — and  generally  some  is  passed 
at  irregular  intervals — is  pale,  watery,  of  low  specific  gravity,  and  want- 
ing in  urea. 

The  watery  character  of  the  urine  under  these  circumstances,  with 
its  low  specific  gravity  and  want  of  color,  are,  as  has  been  shown  by  Dr. 
Roberts,'  important  indications  that  the  secretion  has  taken  place  against 
adverse  pressure.  In  the  normal  dynamic  state  of  the  renal  apparatus 
pressure  exists  within  the  blood-vessels,  but  none  in  the  tubes.  This 
difference  of  pressure  upon  the  two  sides  of  the  membrane  between  the 
blood  and  the  urine  is,  as  has  been  shown  by  experiment,  a  condition  es- 
sential to  secretion.  It  has  been  shown  in  animals  that  when  the  renal 
artery  is  narrowed  by  means  of  a  clamp,  so  as  to  lessen  the  blood-j)res- 


'  "  Paper  on  Obstructive  Suppression  of  Urine,"  Manchester  Med.   and  Surg. 
Beports,  vol.  i.,  p.  2:«. 


332  SUPPRESSION    OF    URINE. 

suro  in  the  kidney,  the  nrine  is  diminished  ;  while  conversely  a  similar 
result  follows  when  the  nrine  is  made  to  exert  pressure  backwards.  A 
column  of  mercury  in  the  ureter  causes  the  urine  to  be  produced  in  di- 
minished quantity  and  with  a  diminished  percentage  of  urea,  the  secre- 
tion becoming  poorer  and  more  scanty  with  each  increase  of  pressure, 
and  at  last  stopping  altogether.  Corresponding  changes  take  place  when 
the  ureter  is  obstructed  in  the  human  being.  The  distention  of  the 
pelvis  at  first  retards  and  then  arrests  the  secretion.  Any  small  quan- 
tities of  nrine  which  the  obstacle  permits  to  escape  during  the  process, 
having  been  secreted  against  pressure,  are  pale,  watery,  and  deficient  in 
urinary  elements.  The  urine  under  the  circumstances  is  sometimes,  but 
not  necessarily,  albuminous.  This  depends  upon  the  previous  state  of 
the  kidney,  and  on  the  amount  of  congestion  which  the  arrest  of  secre- 
tion has  engendered.  There  is  a  total  absence  of  dropsy,  and  unless 
urine  be  retained  in  a  dilated  kidney  or  elsewhere,  there  are  no  urinous 
exhalations  from  the  skin  or  lungs.  There  is  a  progressive  failure  of 
strengtii,  succeeded  almost  always  by  twitching  of  the  voluntar}' muscles. 
The  respiration  becomes  embarrassed  and  the  action  of  the  heart  enfeebled. 
The  digestive  system  is  disturbed,  as  evinced  by  vomiting,  loss  of  ap- 
petite, coating  and  subsequent  dryness  of  the  tongue.  Sometimes  thirst 
is  complained  of.  The  mind  usually  remains  clear,  or  but  slightly  af- 
fected. Occasionally  drowsiness,  or  want  of  sleep,  or  distressing  rest- 
lessness supervenes.  The  pupils,  towards  the  end,  become  contracted. 
Sometimes,  but  by  no  means  constantly,  epileptiform  convulsion  takes 
place,  and  more  rarely  death  is  preceded  by  coma.  More  frequently 
death  takes  place  in  a  somewhat  sudden  manner,  apparently  from 
asthenia. 

Obstructive  suppression  alfects  the  heat  of  the  body  slightly  but  with 
some  constancy.  In  five  cases  of  which  I  have  particulars  before  me, 
the  highest  recorded  temperature  was  100. U,  the  lowest  97.0.  It  is  not 
unusual  for  there  to  be  a  slight  febrile  disturbance  at  the  outset,  indi- 
cated by  the  higher  temperature  :  but  as  the  condition  continues  the 
temperature  usually  becomes  subnormal,  as  is  the  rule  with  uraemia, 
whatever  its  cause  may  be.  Mr.  Hutchinson's  case  of  obstruction  by 
cancer  appears  to  be  peculiar,  insomuch  that  the  temperature  rose, 
instead  of  falling,  as  the  results  of  suppression  declared  them- 
selves. 

The  duration  of  cases  ending  fatally  is  very  variable.  Wliere  the 
urine  has,  before  the  stoppage,  escaped  with  difficulty  and  consequent 
impoverishment,  death  may  occur  after  a  few  days  only  of  total  arrest. 
Dr.  Eoberts  fixes  the  ordinary  duration  of  complete  obstructive  suppres- 
sion at  from  nine  to  eleven  days.  Cases  are  related  in  one  of  which 
total  suppression  lasted  for  twelve  days,  and  in  another  suppression, 
total  but  for  one  interruption,  lasted  for  twenty-two  days.  This  last 
case,  however,  is  very  exceptional  in  its  duration.  In  the  great  majority 
obstructive  suppression  proves  fatal  in  the  course  of  the  second  week. 
The  passage  of  small  quantities  of  such  urine  as  has  been  described 
gives  but  little  protraction. 

The  rare  occurrence  of  suppression  of  urine  m  connection  with 
obstruction  of  the  abdominal  aorta  or  both  renal  arteries  completes  the 
enumeration  of  the  circumstances  especial  to  the  kidney  under  which 
the  secretion  of  urine  may  be  arrested. 

A  case  is  related  by  the  late  Dr.   Todd  in  which  suppression,  nearly 


SUPPRESSION    OF    URINE.  333 

complete  for  five  days,  accompanied  the  formation  of  a  dissecting  aneu- 
rism which  involved  the  aorta  and  probably  the  renal  arteries.' 

Some  interesting  illustrations  of  the  effect  of  obstruction  of  the  aorta 
upon  the  urine  are  given  by  Dr.  Bristowe.''  In  two  instances,  in  which 
the  abdominal  aorta  was  suddenly  obstructed  by  coaguluin  belonging 
to  aneurisms  of  this  vessel,  the  uriue  was  at  "^ first  suppressed,  then 
scanty,  bloody,  and  highly  albuminous.  In  one  of  these  cases  no  urine 
was  passed  for  twenty-four  hours  after  the  presumed  date  of  the  ob- 
struction, and  then  only  three  ounces,  Avliich  were  albuminous  to  two- 
thirds,  and  contained  casts  and  blood.  The  return  of  the  secretion 
after  its  stoppage  is  probably  due  to  the  re-establishment  of  the  circula- 
tion by  the  collateral  channels  which  connect  the  upper  and  lower  jjarts 
of  the  aorta.  The  kidneys  were  found  in  each  case  to  be  greatly  con- 
gested, correspondingly  with  the  evidences  of  nephritis  which  had  been 
evinced  during  life.  The  hyperajmia,  or  inflammation,  might  have  been 
partly  explained  in  one  instance  by  the  jiresence  of  blocks,  or  infarcts, 
derived  from  the  detached  clot,  which  may  have  been  sources  of  irrita- 
tion; but  in  the  other  case  no  such  explanation  was  presented.  It  is  to 
be  observed  that  other  structures  in  the  territory  of  the  obstructed  ves- 
sels— the  bladder  and  rectum  for  example — were  likewise  congested  and 
ecchymosed.  Thus  congestion  of  some  sort,  probably  venous  and  by  re- 
flux, may  be  a  late  result  of  arterial  stoppage.  The  congestion  about 
fibrinous  blocks  is  well  known;  and  it  is  at  least  of  interest  to  associate 
with  these  phenomena  the  nephritis  which  succeeds  upon  the  suppres- 
sion of  collapse. 

Systemic  Suppression"  of  Uriis'e. 

Suspension  of  the  renal  function  may  occur  in  connection  with  cere- 
bral injury  or  concussion,  or  Avith  a  variety  of  other  morbid  conditions, 
of  Avhicli  it  is  to  be  noted  that  they  are  generally  accompanied  either  by 
universal  collapse  or  by  unwonted  discharges  of  fluid  from  some  other 
exit,  or  by  both  these  conditions  conjointly.  Concussion  of  the  brain 
may  be  a  cause  of  transient  but  total  suppression.  The  suspension  of 
nervous  function,  though  chiefly  relating  to  voluntary  movements,  is 
not  confined  to  them,  as  is  seen  by  the  embarrassment  of  respiration 
sometimes  present.  The  kidney,  with  its  ])neumogastric  communica- 
tions, is  especially  under  the  control  of  the  brain,  and  its  action  is  in- 
creased, altered,  or  suspended  by  cerebral  causes.  Suppression  from 
concussion  is  necessarily  transient,  terminated  shortly  either  by  recovery 
or  death. 

There  are  general  states  of  system  expressed  by  the  terms  prostration, 
collapse,  and  exhaustion,  in  which  for  a  time  the  urine  ceases  to  be 
formed.  The  renal  is  suspended  in  common  with  other  functions,  and 
is  restored  with  them  should  reaction  occur. 

The  suspension  is,  in  its  nature,  temporary,  the  secretion  returning 
as  the  strength  of  the  circulation  is  restored  and  the  exhausted  vessels 
are  replenished.  In  some  of  the  conditions  in  which  the  urine  is  thus 
absent,  cholera  and  some  forms  of  poisoning,  at  least  two  causes  may  l)e 
supposed  to  concur — failure  of  circulating  force,  with  loss  of  circulating 
material.     But  we  may  consider  first  a  simple  relationship  which  exists, 

^  Med.-Chir.  Trans.,  vol.  xxvii. 

'Three  cases  of  sudden  obstruction  of  the  abdominal  aorta  by  aneurism,  Lan- 
cet, 18151,  vol.  i.,  p.  133-166. 


334-  SUPPRESSION    OF    UKINE. 

quite  independently  of  depletion  or  change  of  blood,  between  unmixed 
collapse  and  suspension  of  renal  action.  Suppression  from  this  cause 
has  been  frequently  observed  in  connection  with  perforations  of  the 
stomach,  of  the  duodenum,  of  the  jejunum,  of  the  ileum,  from  typhoid 
fever  or  otherwise,  and  in  connection  with  peneti-ation  of  the  large  in- 
testine. It  has  been  known  to  folloAV  laceration  of  the  bile  ducts.  Un- 
der such  circumstances  death  usually  comes  too  rapidly  to  allow  of  any 
very  protracted  suppression,  but  it  has  been  noted  that  as  long  a  time  as  two 
days  has  passed  without  any  secretion.  After  death  it  is  usually  found 
in  these  cases  that  the  bladder  is  empty  and  contracted;  and  it  Avould 
seem  that  not  mere  emptiness,  but  unnatural  contraction  of  that  organ, 
has  in  some  instances  existed  during  life,  as  painful  straining,  a  falla- 
cious sense  of  distention,  and  a  resistance  to  the  catheter  thought  to  be 
unusual,  have  been  observed. 

The  immediate  cause  of  the  symptoms  in  these  cases  is  probably  an 
influence  upon  the  abdominal  centres  of  the  sympathetic  through  irri- 
tation of  the  peritoneum  by  the  extruded  matter.  And  it  is  known  that 
other  causes  of  collapse,  acting  possibly  on  other  nervous  territories,  but 
equally  unconnected  with  any  material  drain,  may  also  be  accompanied 
by  suppression  of  urine. 

In  collapse,  upon  whatever  it  ma}'  depend,  there  appears  to  be  a  gen- 
eral contraction  of  the  arterial  system,  the  blood  being  driven  thence  to 
stagnate  in  the  veins.  The  left  ventricle  is,  as  seen  after  death,  con- 
tracted to  the  utmost,  the  arterial  pulse  everywhere  fails,  becoming  fee- 
ble in  the  large  arteries,  and  imperceptible  in  the  smaller,  while  the 
skin  is  cold  and  cadaverous,  giving  in  warmth  and  color  no  evidence 
of  moving  blood.  The  condition  would  seem  to  be  one  of  hindrance  in 
the  vessels  rather  than  failure  at  the  heart — arterial  closure,  not  cardiac 
weakness.  The  contracted  and  empty  left  ventricle,  unlike  the  re- 
laxed and  loaded  cavity  of  asthenia,  has  done  its  duty.  But  the  blood, 
probably  from  a  kind  of  spasm  affecting  alike  heart  and  arteries,  does 
not  circulate,  the  absence  of  circulation  being,  under  these  circumstances, 
more  complete  than  with  asthenia,  is  long  compatible  with  life.  With, 
the  absence  of  circulation  the  derivatives  of  blood  necessarily  cease  to  be 
formed,  and  urine,  like  other  secretions,  is  in  abeyance. 

Suppression  of  urine  may  be  produced  by  certain  poisons,  especially 
when  their  action  is  attended  with  collajjse.  Corrosive  sublimate  has, 
more  often  than  any  other  poison,  been  followed  by  this  symptom, 
though  the  same  result  has  been  known  to  arise  from  the  mineral  acids, 
putrid  animal  matter,  poisonous  fungi,  and  occasionally  from  arsenic. 

With  regard  to  corrosive  sublimate,  a  poisonous  dose  of  this  substance 
produces  a  condition  of  collapse  which  resembles,  as  Mr.  Sedgewick  has 
shown,'  that  of  cholera;  the  intestinal  discharges  are  usually  but  not  al- 
ways excessive,  and  the  urine,  often  for  several  days,  totally  wanting. 

Taylor*  relates  the  case  of  one  John  Wright,  38  years  of  age,  who 
swallowed  two  drachms  of  corrosive  sublimate,  and  an  hour  afterwards 
was  received  into  Guy's  Hospital. 

It  would  be  easy  to  collect  many  other  instances  of  poisoning  by  cor- 
rosive sublimate  in  which  there  has  for  many  days  been  a  total  cessation 


'  Much  information  regarding  toxic  suppression  of  urine  is  given  by  Mr. 
Sedgewick  in  a  valuable  paper  on  some  analogies  of  cholera.  Med.-Chir.  Trans., 
vol.  li.    p.  1. 

^  Guy's  Hospital  Reports,  1844,  p.  24;  also  Taylor  on  "  Poisons,"  2d  ed.,  p.  447. 


I 


SUPPRESSION    OF    UKINK.  335- 

of  the  urinary  secretion.  Mr.  Sedgewick,  in  the  paper  referred  to, 
quotes  the  case  of  a  boy  who  died  five  days  and  six  hours  after  taking 
this  poison,  where  the  urinary  secretion  during  the  whole  time  was  sus- 
pended, and  the  bhidder  after  death  contracted.  He  mentions  also  a 
servant  girl,  who  died  from  the  effects  of  corrosive  sublimate  on  the 
eighth  day,  with  whom  there  was  total  and  permanent  suppression  ;  no 
urine  could  be  obtained  with  the  catheter,  and  after  death  the  bladder 
was  empty  and  contracted. 

In  such  cases  it  would  appear  that  the  suspension  of  secretion  is  due 
to  the  general  state  of  collajise  rather  than  to  any  change  localized  in 
the  kidneys.  Where  the  kidneys  have  been  examined,  they  have  been 
described  either  as  natural,  or  as  presenting  only  a  slight  degree  of 
congestion,  not  enough  to  add  perceptibly  to  their  bulk  or  materially 
change  their  aspect.  So  slight  a  local  change  is  totally  insufficient  to 
account  for  the  arrest  of  function.  We  must,  therefore,  look  for  the 
cause  of  the  cessation  in  the  state  of  sj'stem  rather  than  of  kidney. 
Two  systemic  causes  of  suppression  may  concur  in  these  cases:  first,  ex- 
haustion by  profuse  discharges,  with  possible  diversion  of  urinary 
fluid;  secondl}',  the  restraint  of  arterial  flow  which  belongs  to  colla])se. 
Of  these  it  is  probable  that  want  of  circulation  has  more  to  do  with  the 
absence  of  urine  than  have  the  diarrhoea  and  vomiting.  The  loss  of  fluid 
in  these  cases  is  not  generally  such  as  would  seem  to  counterbalance  the 
missing  secretion,  and  it  may  be  observed  that  with  poisoning,  more 
especially  with  nitric  acid,  Avhere  similar  suppression  follows,  the  bowels 
are  obstinately  confined.  We  may,  therefore,  presume  that  the  suppres- 
sion of  corrosive  sublimate  is  a  part  of  the  collapse  which  attends  the 
action  of  this  poison. 

With  poisoning  by  nitric  acid  suppression  of  urine  is  especially  asso- 
ciated. Extreme  collapse  is  present  in  these  cases.  There  is  vomiting, 
but  no  diarrhoea;  on  the  contrary,  the  bowels  are  usually  confined,  and 
are  found  after  death  to  be  occupied  by  indurated  fa?ces.  Suppression 
has  also  been  noticed  in  cases  of  poisoning  by  sulphuric  and  hydro- 
chloric acids.  With  regard  to  arsenical  poisoning,  the  urine  is  suppressed 
occasionally  and  for  short  periods,  but  not  with  any  regularity. 

Finally,  suppression  of  urine  has  been  noticed  in  connection  with  the 
choleraic  symptoms  produced  by  putrid  meat  and  poisonous  fungi.  It 
is  probable  that  in  all  these  cases  the  suppression  is  due  to  the  state  of 
circulation  which  constitutes  collapse.  It  is  manifest  that  the  profuse 
loss  of  fluid  by  diarrhoea  and  vomiting  which  occurs  in  some  forms  of 
poisoning  and  in  cholera  must  also  tend  to  diminish  the  urine.  Sup- 
pression may,  therefore,  be  especially  looked  for  where  profuse  discharges 
have  produced,  or  coexist  with,  a  condition  of  collapse.  Cholera  and 
poisoning  by  corrosive  sublimate  are  the  typical  examples  of  this  morbid 
concurrence. 

The  suppression  of  cholera  is  complicated,  partly  systemic  and  partly 
renal,  arising  from  general,  but  frequently  protracted  by  local  causes. 
In  the  cold  stage  there  is,  as  a  result  of  the  intestinal  drain,  the  gen- 
eral condition  of  arterial  emptiness,  the  loss  being  especially  of  the 
water  of  the  blood,  which  is  essential  to  the  solution  and  elimination 
of  the  urinary  elements.     The  rice-water  evacuations  of  cholera'   are 

1  On  the  intestinal  discharges  in  cholera,  Dr.  Parkes,  Loud.  Journ.  of  Med., 
1849,  p.  134. 

Reports  on  epidemic  cholera,  published  by  the  College  of  Physicians,  Path. 
Report,  by  Dr.  Gull,  p.  44. 


3:3(1  SUPPRESSION    OF    URINE. 

chiefly  aqueous,  insomucli  that  on  an  average  100  parts  of  rice-water 
stools  contain  more  than  98  of  water,  the  small  amount  of  solid  matter 
consisting  chietly  of  salts  of  potash  and  soda,  with  only  a  trace  of  albu- 
min. They  contain  no  urea,  and  of  uric  acid  have  given  but  rare  and 
doubtful  indications.  They  take  the  water,  but  leave  the  renal  exere- 
menta.  Tbe  blood  accordingly  becomes  viscid;  its  specific  gravity  is 
greatly  increased;  its  water  is  lessened;  the  organic  solids  are  propor- 
tionally raised,  after  much  purging,  even  to  half  as  much  again  as  in 
health,'  and  urea  is  constantly  found.  This  condition  of  dehydration, 
together  Avith  the  failure  of  circulation  which  accompanies  it,  produces 
a  general  suspension  of  all  the  fluid  secretions  which  are  not  under  the 
stimulus  of  the  disease.  Urine  may  accordingly  be  absent  during 
collapse  for  thirty  hours,  or  even  longer.  But,  though  unable  to  re- 
spond by  secretion,  the  kidneys,  even  at  this  stage,  give  evidence  of  ir- 
Titation,"^  which  we  must  ascribe  rather  to  the  urinary  elements  in  the 
blood  than  to  any  direct  influence  of  the  cholera  poison.  The  kidneys, 
if  examined  during  or  immediately  after  the  stage  of  collapse,  though 
not  as  yet  much  altered  in  bulk,  are  congested  sometimes  to  a  general 
violet  tint,  some  excess  and  some  alteration  of  epithelium  is  found  in 
the  tubes  of  the  cortex,  while  those  of  the  cones  frequently  contain 
crystals  of  uric  acid  or  oxalate  of  lime.  'With  these  signs  of  incipient 
inflammation,  the  urine  as  it  begins  to  reappear  is  scanty,  albuminous, 
sometimes  bloody,  and  loaded  Avith  casts,  usually  of  the  epithelial  type. 
The  kidneys  may  now  gradually  right  themselves,  or  it  may  happen  that 
the  symptoms  and  local  changes  of  acute  tubal  nephritis  maydevelop. 
Early  and  marked  uriemia  occurs — it  appears,  indeed,  that  what  is  termed 
the  consecutive  fever,  or  the  typhoid  strge  of  cholera,  so  far  resembles 
uremia  in  its  symptoms  that  we  cannot  but  regard  this  condition  of 
blood  as  one  of  its  pathological  factors.'  The  kidneys  under  these  cir- 
cumstances are  found  to  be  m  a  condition  of  tubal  nephritis,  they  are  much 
increased  in  bulk,  weighing,  as  in  a  case  mentioned  by  Dr.  Gull,  15^ 
ounces;  they  are  pale,  loaded  Avith  more  or  less  fatty  epithelium,  and  are, 
in  short,  in'  a  tvpical  condition  of  tubal  inflammation,  not  unlike  that 
Avhich  results  from  exposure  to  cold.  The  urine  is  scanty,  albuminous, 
and  deficient  in  urea,  and  occasionally  dropsy  ensues._  We  thus  have  in 
cholera  a  condition  of  complete  suppression  arising  in  dehydration  and 
collapse,  and  succeeded  by  partial  suppression  depending  upon  renal 
inflammation. 

A  cause  of  transient  suppression,  connected  presumably  Avith  renal 
congestion,  maybe  occasionally  found  in  the  so-callea  cold  stage  of  ague, 
under  Avhich  influence  the  urine  has  been  known  to  be  absent  for  a  time, 
to  reappear  albuminous  or  bloody.  AVe  may  attribute  the  accident  to 
the  driving  inwards  of  the  blood  upon  the  kidneys  as  upon  other  inter- 
nal organs. 

In  cases  of  intestinal  obstruction,  the  urine  is  often  much  dimin- 
ished, and  sometimes  entirely  withheld. 

It  has  been  generally  stated  that  the  amount  of  urine  formed  with 
intestinal  stoppage  is  a  guide  to  the  ^losition  of  the  obstacle — the  higher 
the  obstacle  the  less  the  urine — the  diminution  of  the  secretion  depend- 
ing, as  Avas  thought,  upon  the  loss  of  the  absorbing  surface  below 
loAV  the  stricture.    But  as  Dr.  Brinton  has  shoAvn,  this  relationship  is  by 


1  Report  on  epidemic  cholera,  published  by  the  College  of  Phj'sicians,  Path. 
Report,  by  Dr.  Gull,  p.  187. 


SUPPRESSION    OF    URINE.  337 

uo  means  invariable,  copious  urine  sometimes  concurring  with  a  high 
obstruction,  and  scanty  or  temporarily-suppressed  urine  with  a  low  one. 
Besides  the  mere  loss  of  absorbing  surface,  there  are  at  least  two  otlier 
morbid  conditions  to  consider  in  connection  with  the  renal  secretion 
under  these  circumstances;  first,  the  drain  of  fluid  by  vomiting,  which, 
especially  when  the  obstruction  is  near  the  stomach,  is  profuse,  and  ap- 
parently out  of  proportion  to  what  has  been  swallowed;  and  se3ondly, 
the  collapse,  so  often  productive,  as  has  been  shown,  of  anuria,  but 
which  has  relation  to  the  nature  of  the  lesion  rather  than  to  its  posi- 
tion. 

22 


INDEX. 


Abdominal  tumor  from  renal  disease, 
40 
tumor  simulating  renal  dis- 
ease, 44 
tumor       from       hydrone- 
phrosis, 101 
Abscess  of  kidney,  1 

of  kidney,  pyaemic,  5 
of  kidney,  toxic,  4 
of  kidney,  traumatic,  1 
of  kidney,  uriseptic  or  surgi- 
cal, 8 
Acids,  mineral,  for  alkalinity  of  urine, 
15,  146 
mineral,  for  phosphuria,  295 
Adolescents,  albuminuria  of,  314 
Age  of  subjects  of  malignant  disease 
of  kidney,  48 
of  subjects  of  tubercular  disease  of 
kidney,  87 
Ague  in  heematuria,  325 

in  intermittent  haematuria,  276 
Albumin,  tests  for,  in  urine,  300 
peculiar,  in  urine,  303 
Albuminuria  of  adolescents,  314 
alimentary,  315 
from  blood  disorders,  315 
causes  of,  generally  con- 
sidered, 304 
classification  of,  304 
from  cholera,  311 
with     exophthalmic 

goitre,  313 
with  hepatic  disturbance, 

316 
of  nervous  origin,  313 
with  pneumonia,  307 
with  pja'exia,  311 
relations  of,   in  general, 

300 
renal  diseases  as  causes 
of,  306 
Alcohol,  in  causation  of  intermittent 

haematuria,  277 
Alimentary  albuminuria,  315 
Alkalies,  intolerance  of,  in  pliosphuria, 
295 
as  solvents  for  stone,  194 
Allbutt,  Clifford,  on  albuminuria  from 
mental  causes,  313 


Ammoniacal  urine,  145 
Amyloid,  see  Lardaceous 
Angioma  of  kidney,  67 
Arteries,  renal,  diseases  of,  224 

obstruction  of.   as  cause 
suppression,  333 


of 


Beale,  on  chyluria,  256 

Bernard,  Claude,  on  albuminuria,  313, 

315 
Bilharzia  haematobia,  337 
Bladder,  cancer  of,  321 

disease  of,   as  cause  of  sup- 
pression, 331 
haematuria    connected    with, 

331 
naevus  of,  333 
villus  of,  323 
Blood  with  hajmoglobinuria,  285 

in  urine,  tests  for,  317 
Blood-calculi,  151 
Blood-corpuscles  with  haemoglobinuria. 

385 
Bony  growths  in  kidney,  68 
Bowel,  relation  of.  to  renal  tumors,  38 
perforated  b}'  renal  tumors,  53 
Bronchial  tubes,  perforation  of,  from 
renal  calculus,  170 
tubes,     perforation    of,    in 
perinephritis,  24 

Calcareous  formation  in  kidney,  68 
Calculi,  renal,  calcic  carbonate,  147 
renal,  cystine,  148 
renal,  differential  diagnosis  of. 

153 
renal,  fibrinous,  151 
renal,    general     considerations 

concerning,  130 
renal,  geographical  distribution 

of,  136 
renal,  indigo,  151 
renal,    insanity    and    epilepsy 

with,  176  ' 

renal,  kinds  of,  120 
renal,  modes  of  death  from,  166 
renal,  in  Museums  of  London, 

133 
renal,  oxalate  of  lime,  136 


340 


INDEX 


Calculi,  renal,  pathological  consequen- 
ces of,  155 
renal,  pliosphatic,  141 
renal,  pyelitis  from,  1(58 
renal,  symptoms  of,  157 
renal,  suppuration    from     out- 
side kidney. 170 
renal,  suppression      of     urine 

from.  172 
renal,  triple  x^liosphate,  141 
renal,  urates,  184 
renal,  uric  acid,  128 
renal,  urostealitii,  152 
renal,  water  and  food  in  con- 
nection witli,  127,  128 
renal,  xanthine,  135 
Calculus,  renal,  treatment  of.  177 
renal,  by  operation.  181 
renal,  by  solvents,  194 
Cancer  cells  in  urine,  321,  322 
Cantharides,  as  cause  of  renal  abscess, 

4 
Carcinoma  of  kidney,  53 
Carter,  A^andyke,  on  chyluria,  252 
Cartilaginous"  growths  in  kidney,  68 
Casts    with    intermittent    hajmaturia 

281,  282,  283 
Causes  of  floating  kidney,  207 
of  liEematuria,  319 
of  hydronephrosis,  95 
of  intermittent   hsematuria,  276 
of  pyelitis.  16 
Chlorate  of  "potash  as  cause  of  haemo- 

globinuria,  288 
Chlorine  in    intermittent    hsematuria, 

285 
Cholera,  albuminuria  with,  311 

as    cause    of     suppression    of 
urine,  335 
Chylorrhoea,  261 
Chyluria,  251 

pathology  of  269 
treatment  of,  272 
Cobbold,  on  parasites,  chap,  xviii.,  227 
Cold,  as  cause   of  intermittent  haema- 

turia,  278 
Collapse  as  cause  of  suppression,  333 
Colloid  of  kidney,  55,  101 
Concussion  of  brain  a  cause  of  suppres- 
sion, 333 
Contrexeville  water  for  calculi,  198 
Cystic  disease  of  kidney,  109 

disease    of    kidney,  congenital, 
117 
Cystine  calculi,  148 
Cysts,  paianephric,  118 

renal,  simulating  hydronephro- 
sis. 102 
renal,  solitary,  118 

Davaine,    on    renal     parasites,     chap. 

xviii.,  227 
Depurative,  see  Lardaceous 
Diathesis,  cystic,  148 

phospliatic,  141 

oxalic,  136 


Diathesis,  uric,  128 
Diet  in  uric  acid  diatnesis,  133 
Discharges  of  chyle  from  surface,  261 
Displacement  of  "kidney,  205 
Distribution,    geographical,   of  calculi, 
126 
geographical,  of  chyluria, 
253 
Duration  of  malignant  disease   of   kid- 
ney, 75 
of  tubercle  of  kidney,  92 

Earths  in  urine  of  phosphuria,  296 
Elliotson,  hfematuria  with  ague,  275 
Embolism,  renal,  33 
Encephaloid  of  kidney,  54 
Epilepsy,  with  renal  calculi,  176 
Epithelial  cancer  of  kidney,  55 
Epitlielium,    urinary  characters  of,  in 

different  parts.  19 
Ergot  in  htymaturia,  327 
Etiology,  see  (pauses 
Excision  of  kidney,  see  Nephrectomy 

of  stone,  see  Lithotomy 
Exophthalmic  goitre  as  cause  of  albu- 
minuria, 313 

Fibrinous  calculi,  151 
Fibrous  renal  tumors,  60,  68 
Filaria,  264 
Floating  kidney,  205 

kidney,  excision  of,  213 
Frank  on  chyluria,  251 

Gangrene,   symmetrical,    with   lijemo- 

globinuria,  279,  289,  291 
Gay  Lussac,  on  solution  of  calculi.  196 
Geographical   distribution    of    calculi, 
126 
distribution  of  chyluria, 
253 
Glandular  tumors  simulating  renal,  43 
Globulin  in  urine,  303 
Glomerular   nephritis  a  cause  of  sup- 
pression, 329 
Graves,  on  urinary  paralysis,  217 
Greeve,  on  Leth- Albumin,  300 
Gubler,  on  chyluria,  252 
Gull,  on  hrematiuuria,  274,  283 
on  urinary  paralysis,  217 

Hsematinuria,    see   Haematuria,    inter- 
mittent 
Hsematuria,  causes  of.  319 
endemic,  237 
generally  considered,  317 
from  improper  food  with 

infants,  324 
from  malaria,  325 
from  mental  emotion,  324 
from  na^vus    of    bladder, 

333 
from  purpura  and  scurvy, 
324 


INDEX. 


34:1 


Haematuria,  renal,  319 
simple.  325 
from  stone  and  growths, 

163,  163,  321 
toxic,  320 
treatment  of,  326 
vicarious,  324 
vesical,  321 

from  villus  of  bladder,  322 
intermittent,  274 
intermittent,   abortive  at- 
tacks of,  279 
intermittent,  pathology  of, 

285 
intermittent,  rationale  of, 

290 
intermittent,       treatment 

of,  291 
intermittent,  urine  with, 
280 
Hsemoglobinuria,  see  Hematuria,    in- 
termittent 
toxic,  288 
Hard  water  as  cause  of  calculi,  127,  128 
Harley,  George,  on  intermittent  haema- 
turia, 275 
John,  on  the  Bilharzia,  237,  241 
Hassall,  on  the  phosphatie  diathesis, 

294 
Head  symptoms    with  suppression  of 

urine,  332 
Healthy  epitlielium,  microscopic  char- 
acter of,  19 
Hepatic  disturbance  a  cause  of   albu- 
minuria, 316 
Heredity   in  relation    to    intermittent 

haematuria,  277 
Hydatids,  renal,  927 
Hydrsemia  as  a  cause  of  albuminuria, 

315 
Hydronephrosis,  94 

excision  of  kidney  for, 

108 
as  cause  of    suppres- 
sion, 330 

Indigo  calculus,  151 
Insanity  with  renal  calculi,  176 
Intermittent  fever  as  cause  of  haema- 
turia, 325 
fever  as  cause  of  hajmo- 

globinuria,  276 
haematuria,  see  Haematu- 
ria, intermittent 
Intestinal  obstruction  as  cause  of  sup- 
pression, 336 

Jaundice,  with  intermittent  haematu- 
ria, 279 
Jones,  Bence,  on  chyluria,  252 

Bence,  on  phosphatie  diathesis, 

298 
Bence,  on  peculiar  albumin,  301 

Kidney  in  chyluria,  260 


Kidney  in  intermittent  haematuria,  285 

Lardaceous  disease,  tubercle    of    kid- 
ney with,  91 
Leukhaemia  of  kidnej%  66 
Lewis,  on  chyluria,  252 
Lime  in  urine,  294 

water  in  solution  of  calculi,  197 
Lithia  in  solution  of  calculi,  200 
Lithotomy,  renal,  181 
Lymphadenoma  of  kidney,  66 

Mackenzie,  morbid  anatomy  of  chylu- 
ria, 270 
Magnesia  in  phosphuria,  296 
Malaria  in  relation  to  haematuria.  325 
in     relation     to     intermittent 
haematuria,  276 
Malignant  disease  of  kidney,    clinical 
history  of,  70 
disease  of  kidney,  duration 

of,  75 
disease  of  kidney,  nephrec- 
tomy for,  76 
disease  of  kidney,  treatment 

of,  76 
disease     of    kidney,     urine 
with,  73 
Malpighian  bodies  in  cystic  disease  of 

kidney,  113 
Marcet,  the  elder,  on  solution  of  calculi, 

195 
Masturbation  as  cause  of  albuminuria, 

314 
Melanosis  of  kidney,  60 
Mental  causes  of  haematuria,  324 
Mineral  acids  for  alkaline  urine,  15 

acids  for  phosphuria,  295 
Misplacement  of  kidney,  204 
Movable  kidney,  205 

kidney,  treatment  of,  212 
Moxon  on  albuminuria  of  adolescents, 
314 

Naevus  as  cause  of  haematuria,  323 
Nephrectomy  for  hydronephrosis,  108 
for  malignant  disease,  76 
for  movable  kidney,  213 
for  stone,  181 
for  tubercle,  93 
Nephritis  from  intermittent  haematu- 
ria, 280 

Ord,  on  indigo  calculus,  151 

on  renal  calculi,  125 
Owen,  on  albuminuria  in  pneumonia, 

307 
Oxalate  of  lime  calculi,  136 

Paralysis,  urinary,  215 
Paranephric  cysts,  118 
Paraplegia  with  hyatids  of  kidney,  234 
with  malignant  disease    of 
kidney,  72 


342 


INDEX. 


Pavy,  on  paroxysmal  hcematuria,  274: 
Peptones  in  urine,  8U"3 
Perinephritis,  2'S 

puerperal,  37 
Phosphuria,  294 

with  diabetes,  298 
treatment  of,  295 
Plymouth  Dockyard  disease,  26 
Pneumonia  as  cause  of  albuminuria,  307 
Potash  in  solution  of  calculi,  199 
Prout,  on  chyluria,  196 

on  haamaturia  with  malaria,  275 
on  phosphatic  diathesis,  294 
Psoas  abscess,  from  perinephritis,  24 
Purpura  and  scurvy  as  causes  of  albu- 
minuria, 316 
and  scurvy  as  causes  of  hasma- 
turia,  324 
Pyaemia  of  kidney,  5 
Pyelitis,  16 

from  calculi,  168 
Pyrexia,  albuminuria  with,  311 

Renal  calculi,  see  Calculi 

Reynaud's    disease   with    hsemoglobin- 

uria,  279,  289,  291 
Roberts,  W.,  on  hydronephrosis,  107 

W.,  on  malignant  tumor,   49, 

51 
W.,  on  movable  kidneys,  205 
W.,  on  solution  of  calculi,  196 
W.,  on  suppression  from  cal- 
culi, 173 

Sarcoma  of  kidney,  56 

Saundby,  on  frequency  of  albuminuria, 

304 
Sex  in  relation  to  floating  kidney,  205 
Soda  in  solution  of  calculi,  199 
Spectroscope  in  haematuria,  317 

in  haemoglobinuria,  281 
Spine  involved  in  renal  tumors,  51 
Spurious  urinary  parasites,  249 
Stanley,  on  urinary  paralysis,  216 
Stephens,   Joanna,   her  stone    solvent, 

195 
Stone,  see  Calculus 
Strongulus  gigas,  244 
Suppression  of  urine  from  arterial  ob- 
struction, 332 
of  urine  from  calculi,  173, 

179,  330 
of  urine  from  cholera,  335 
of  urine  from  collapse,  333 
of  urine  generally  consid- 
ered, 328 
of    urine    from    hydrone- 
phrosis, 330 
of    urine    from   intestinal 

obstruction,  336 
of  urine  of  nervous  origin, 

333 
of  urine,  obstructive,  330 
of  urine  from  poisons,  334 
of  urine  from  renal   sup- 
puration, 7,  329 


Suppression   of     urine    from    surgical 

operations,  329 
Suppuration  antecedent  to  intermittent 
haematuria,  277 
bevond  kidney,  from  cal- 
culi. 170 
Supra-renal  tumors  distinguished  from 

renal,  43 
Surgery  of  hydronephrosis,  108 
of  movable  kidney,  213 
of  renal  calculi,  181 
of  renal  tumors,  76 
of  tubercle  of  kidney,  93 
Surgical  kidney,  8 
Syphilis  with  intermittent  haematuria, 

277 
Syphiloma  of  kidney,  67 


Temperature  of  bodj^  with  intermittent 
hgematuria,  279 
of  body  with  suppression, 
332 
Tetrastoma  renale,  249 
Toxic  albummuria,  307 
Traumatic  abscess  of  kidney,  1 
Tubal  nephritis,  see  Nephritis 
Tubercle  of  kidney.  79 

of  kidney,   abdominal  tumor 

from,  89 
of  kidney,  age    in  regard  to, 

87 
of  kidney,  causes  of,  88 
of  kidney,  clinical  history  of, 

87 
of  kidney,  lardaceous  disease 

with,  91 
of  kidney,  minute  anatomy  of, 

82 
of  kidney,   with  tuberculosis 

elsewhere,  85 
of  kidney,  treatment  of,  92 
of  kidnev,  urine  with,  91 
of  pelvis,  84 
Tumor,  abdominal,  from  cystic  disease 
of  kidney,  116 
abdominal,  from  glandular  dis- 
ease, 43 
abdominal,  from  hydronephro- 
sis, 104 
abdominal,  from  renal  growths, 

41,  48 
abdominal,     from     supra-renal 

growths,  43 
abdominal,  from  tubercular  dis- 
ease of  kidney,  89 
Tumors,  renal,  dissemination  and  spread 
of,  51 
renal,  distinguished  from  those 

of  other  organs,  42 
renal,  general  relations  of,  37 
renal,  fibrous,  60 
renal,    pathological     varieties 

of,  47 
renal,  primary  and  secondary, 
48 


INDEX. 


343 


Tumors,  renal,   secondary  to  those  of 
kidney,  50 

Uraemia  with  obstruction  of  ureter,  331 
Urates,  calculi  of,  134 
Ureter,  diseases  of,  221 

obstruction  of,  381 
Uric  acid  diathesis,  128 

acid  calculi,  128 
Urine,  with  chyluria,  255 

with  cystic  disease  of  kidney, 

116 
with  hydronephrosis,  104 
with    intermittent    haematuria, 

280 
with  malignant  disease  of  kid- 
ney, 73 
with  phosphuria,  295 
with  suppression,  172,  328 
witli  tubercle  of  kidney,  91 


Uriseptic  abscesses  of  kidney,  8 

Urostealith  calculi,  152 

Urticaria  with  intermittent  hsematuria, 
279 

Uterine  disease  as  cause  of  hydrone- 
phrosis, 98 
f 

Villusof  bladder,  322 

of  bladder,  detachment  of,  32S 

of  kidney,  65 
Vomiting  with  calculus,  162 

Water,  hard,  in  calculous  disease,  127, 
128 
injection  of,  as  ca  ise  of  albumi- 
nuria, 315 

Waxy,  see  Lardaceous 

Xanthine  calculi,  135 


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